# Presentation: 211320

## Caregivers ARE Quality in Long Term Care

- Christine T. Kovner, R.N., Ph.D.
- Division of Nursing, Steinhardt School of Education, NYU
- April 30, 2003

**Notes:**
This is Christine Kovner’s title slide.

## Total Nurse Staffing Hours per Resident per Day, 2001

- Certified nurse aides (CNA)- 2.1 hours
- Licensed practical/vocational nurse (LPN/LVN) - 0.7 hours
- Registered nurses (RN) – 0.7 hours
- Only RN hours have increased from 0.4 hours per day in 1993, while acuity has increased
- 	Harrington from CMS OSCAR data

**Notes:**
This slide lists the statistics for total nurse staffing hours per resident per day in 2001.

##  Reported Staff Ratios on each Shift – Nursing Homes 2001

- 1 CNA to 11.8 Residents
- 1 LVN/LPN to 34 Residents
- 1 RN to  32 Residents 	**	****	**
**Harrington from CMS OSCAR data**

**Notes:**
This lists the reported staff ratios on each shift (e.g., for each type of nurse) in nursing homes in 2001.

## Research Studies: Positive Relationship Between Licensed Nurses & Quality

- Increased licensed nursing hours were related to improved functional ability and decreased probability of death
- Facilities with higher nurse staffing levels have fewer deficiencies
- Facilities with more RNs per LPN had fewer  assessment deficiencies
- 	Bliesmer et al., 1998; Harrington et al., 2000; Moseley & Jones, 2003

**Notes:**
This describes the relationship between licensed nurses and quality in nursing homes.

## Research Studies: Positive Relationship Between Licensed Nurses & Quality

- Nursing homes meeting HHS preferred minimum staffing levels had no violation that caused actual harm to patients
- 68% of homes that did not meet HHS standards had such violations
- Less than 2.0 hours of nurse aid care per nursing home resident were almost 4 times more likely to get pressure sores than those in nursing homes that provided more than 2 hours
- 	(Stark report, 2001); (DHHS Report to Congress: Appropriateness of Minimum Nursing Staffing Ratios in Nursing Homes, 12- 1 (Spring 2000).

**Notes:**
This uses research studies to show there is a positive relationship between licensed nurses and quality.

## Medication Errors in Home Care for Patients 65 years and older

- 1.4% of patients taking medications older adults should always avoid
- 8.4% of patients taking medications rarely appropriate for older adults
- 	Kovner, Menezes, & Feldman, 2003; MEPS data from AHRQ

**Notes:**
Theses are statistics on the prevalence of medication errors in home care for patients 65 years and older.

## Occupational Training Requirements 

- 	Many believe minimum training for nursing assistants should be increased:
- Nursing Assistants --75 hours
- Manicurists -- 400 hours
- Barber -- 1500 hours
- 	www.barbercosmo.ca.gov/

**Notes:**
This shows that significantly less training hours are required for nursing assistants than manicurists and barbers.

## Recommended Nursing Hours in NHs (direct and indirect) 

| Registered Nurses | 69 minutes (1.15 hours) per day  |
| --- | --- |
| Licensed practical/ vocational nurses | 42 minutes (.70 hours) per day |
| Nursing assistants | 162 minutes (2.7 hours) per day |
| Total Nursing | 273 minutes (4.55 hours) per day |

- Harrington, C., Kovner, C., et al. (2000).  Experts recommend minimum nurse staffing standards for nursing facilities in the U.S.  _The Gerontologist_ 40, 5-16.

**Notes:**
This chart shows the minimum nurse staffing standards for nursing facilities in the U.S. recommended by experts.

## Geriatric Preparation

- Less than <1% (21,500) of working RNs are certified in geriatrics
- Fewer than 0.3% (333) of the 97,362 physician residents slots are for geriatrics
- Only 0.3% (720) of 200,000 pharmacists have geriatric certification
- 	Kovner, C.T., Mezey, M., & Harrington, C. (2002).

**Notes:**
This provides statistics on the number of working RNs who are certified in geriatrics, the number of pharmacists who are certified in geriatrics, and the number of physician residents slots that are for geriatrics.

## References 

- Anderson, R. A., Hsieh, P., Su, H. (1998). Resource allocation and resident outcomes in nursing homes: Comparisons between the best and worst. Research in Nursing and Health, 21, 297-313.
- Kovner, C.T., Menezes, J. & Feldman, P. (2003). Paper in progress.
- Harrington, C., Kovner, C., Mezey, M., Kayser-Jones, J., Berger, S., Muhler, M., Reilly, K., Burice, R., Zimmerman, D. (2000).  Experts recommend minimum nurse staffing standards for nursing facilities in the U.S.  _The Gerontologist 40_, 5-16.
- Kovner, C.T., Mezey, M., & Harrington, C. (2002).  Who cares for older adults?  Workforce implications of an aging Society.  _Health Affairs 21(5)_, 78-89.
- Bliesmer, M. M., Smayling, M. , Kane, R. & Shannon, I. (1998) The relationship between nursing staffing levels and nursing home outcomes. Journal of Aging and Health, 10(3), 351-371.
- Harrington, C. Zimmerman, D., Karon, S. L., Robinson, J. & Beutel, P. (2000). Nursing home staffing and its relationship to deficiencies. Journal of Gerontology: Social Sciences, 55B(5), S278-S287.
- Linn, M. G., L. & Linn, B. A. (1977). Patient outcomes as a measure of quality of nursing home care. American Journal of Public Health. 67(4), 337-344.
- Nyman, J. A. (1988). Improving the quality of nursing home outcomes: Are adequacy or incentive-oriented policies more effective? Medical Care, 26(12), 1158-1171.
- Kayser-Jones, Wiener, C. L.  & Barbaccia, J. C. (1989). Factors contributing to the hospitalization of nursing home residents. The Gerontologist, 29, 502-510.
- Spector, W. D., & Takada, H. A.  (1991). Characteristics of nursing homes that affect resident outcomes. Journal of Aging and Health 3(4), 427-454.
- Cherry, R. L. (1991). Agents of nursing home quality of care: Ombudsman and staff ratios revised. The Gerontologist. 31, 302-308.
- Kayser-Jones, J. & Schell, E. (1997). The effect of staffing on the quality of care at mealtime. Nursing Outlook, 45(2), 64-72.
- Harrington, C., Carrillo, H., Thollaug, S., & Summers, P. (1999)Nursing facilties, staffing, residents, and facility deficiencies 1991-1997. (Report prepared for the Health Care Financing Administration. San Francisco: University of California.

**Notes:**
This contains the full citations for all of the works referenced in this presentation.