Entrepreneurial program of research and service to improve nursing home care

Quality of Care In Nursing Homes In Brazil

BACKGROUND

There is an increased demand for nursing homes (NHs) in middle-income countries such as Brazil. To monitor the quality of NHs, there is a need for reliable instruments to assess the extent to which the care provided meets the expectations and rights of residents and their families.

PURPOSE

To evaluate the reliability, applicability, and measurement results of an instrument for assessing the quality of NH care assessment.

METHODS

We conducted a cross-sectional study in 31 NHs, applying the Observable Indicators of Nursing Home Care Quality Instrument (OINHQ) adapted to the Brazilian context. The instrument includes 30 infrastructure and process indicators measured by direct observation grouped into seven domains: Communication; Care Delivery; Grooming; Odors; Environment-Basic; Environment-Access; and Environment-Homelike. To assess feasibility and reliability, 3 pairs of raters with different profiles (health professionals, health inspectors, and potential residents) were independently involved in data collection. We calculated Cronbach α for internal consistency of the instrument, Overall Agreement Index (OAI), and Prevalence-Adjusted Bias-Adjusted Kappa (PABAκ) for interrater reliability and analyzed the baseline NH quality through individual indicators, dimensions, and facilities.

RESULTS

The OINHQ was in general reliable, with good internal consistency (Cronbach α = 0.93) and interrater agreement (mean OAI = 75%; PABAκ = 0.49). NH quality is not homogeneous (overall mean = 2.9, ranging by facility between 1.9 and 3.7, on a scale of 1-5). Process-related indicators (mean = 2.7) are generally worse than structure-related indicators (mean = 3.5). The best domains were associated with Odors (mean = 4.1) and Grooming (mean = 3.9), whereas the priority domains for receiving improvement interventions were Care Delivery (mean = 2.0) and Environment-Homelike (mean = 2.5).

CONCLUSIONS

Baseline evaluation of NH quality shows remarkable variability among facilities and ample room for improvement.

Helping nursing homes "at risk" for quality problems: a statewide evaluation

The Quality Improvement Program for Missouri (QIPMO), a state school of nursing project to improve quality of care and resident outcomes in nursing homes, has a special focus to help nursing homes identified as "at risk" for quality concerns. In fiscal year 2006, 92 of 492 Medicaid-certified facilities were identified as "at risk" using quality indicators (QIs) derived from Minimum Data Set (MDS) data. Sixty of the 92 facilities accepted offered on-site clinical consultations by gerontological expert nurses with graduate nursing education. Content of consultations include quality improvement, MDS, care planning, evidence-based practice, and effective teamwork. The 60 "at-risk" facilities improved scores 4%-41% for 5 QIs: pressure ulcers (overall and high risk), weight loss, bedfast residents, and falls; other facilities in the state did not. Estimated cost savings (based on prior cost research) for 444 residents who avoided developing these clinical problems in participating "at-risk" facilities was more than $1.5 million for fiscal year 2006. These are similar to estimated savings of $1.6 million for fiscal year 2005 when 439 residents in "at-risk" facilities avoided clinical problems. Estimated savings exceed the total program cost by more than $1 million annually. QI improvements demonstrate the clinical effectiveness of on-site clinical consultation by gerontological expert nurses with graduate nursing education.