SEARCH

SEARCH BY CITATION

Keywords:

  • Quality measures;
  • accreditation;
  • rehabilitation nursing;
  • nursing home care

Abstract

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Acknowledgments
  7. References

Purpose

To examine accreditation from nursing homes accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF) and whether this is associated with improved rehabilitation care.

Design

Cross-sectional association of CARF accreditation and quality.

Methods

Comparison of the short-stay quality measures (influenza and pneumococcal vaccination; pain; delirium; pressures sores; five-star quality and health inspection scores) between the sample of 246 CARF-accredited homes compared with the 15,393 nursing homes in the 2010 On-Line Survey Certification of Automated Records (OSCAR).

Findings

CARF-accredited nursing homes demonstrate better quality with regard to the short-stay quality measures.

Conclusions

Approaches beyond traditional regulation and governmental inspections are necessary to improve the quality of care in nursing homes.

Clinical Relevance

During a patient's rehabilitation stay, minimizing iatrogenic complications is paramount. Given the findings of this study, it is unfortunate that very few nursing homes are CARF accredited.

Voluntary accreditation has been proposed as a means of promoting quality in U.S. nursing homes (Griffin, 1987). In this research, we examine accreditation from the Commission on Accreditation of Rehabilitation Facilities (CARF) and whether this is associated with improved rehabilitative care.

Accreditation is a formal evaluation process intended to assess the quality of services provided, facilitate improvements in efficiency, and allow benchmarking comparisons with other organizations. It is largely viewed as a means of publicly demonstrating an organizational commitment to quality and accountability (Nicklin & Dickson, 2009). The literature reveals a number of benefits associated with accreditation across different sectors. Some of these benefits include: facilitating effective risk management, improving performance and service quality, and strengthening interdisciplinary team effectiveness (Mays, Halverson & Scutchfield, 2004; Nicklin & Dickson, 2009).

Rehabilitation Care in Nursing Homes

The history of the U.S. nursing home industry has been characterized by cycles of public demand for quality improvement followed by governmental responses that have often proven ineffective (Winzelberg, 2003). Recent government reports and empirical research continue to identify poor quality in many nursing homes (Castle & Ferguson, 2010). These problems have likely been compounded by decreasing hospital stays, resulting in the discharge of more medically fragile patients to nursing homes for rehabilitation (Morrisey, Sloan & Valvona, 1988). Despite the demonstrated efficacy of different rehabilitative interventions (Morris et al., 1999; Moseley, 1996; Mulrow, 1994; Murray, Singer, Dawson, Thomas & Cebul, 2003), many nursing homes have not developed organizational philosophies and programs that promote individualized rehabilitation for most residents. Potential barriers to implementation of comprehensive rehabilitation programs include an absence of institutional support, lack of professional staff training, and misconceptions about the benefits of initiating rehabilitative practices (Morris et al., 1999). Rehabilitation care in nursing homes is highly variable in terms of staffing practices, the number of residents enrolled in rehabilitative therapies, and facility discharge rates (Kochersberger, Hielema & Westlund,1994).

Approximately 1.5 million elderly people undergo rehabilitation in nursing homes each year. Rehabilitative care can include physical, occupational, and speech therapies or restorative nursing care (Joseph & Wanlass, 1993). Empirical research has demonstrated that rehabilitation in the nursing home can increase community discharge rates, extend survival, improve mobility, and reduce functional decline (Morris et al., 1999; Moseley, 1996; Mulrow, 1994; Murray et al., 2003); however, development of rehabilitation capacity has remained a challenge for many facilities (Morris et al., 1999). Rehabilitation-centered voluntary accreditation has the potential to assist nursing homes in reaching this capacity.

The goals of rehabilitative care will differ depending on a facility's residents. There are two types of residents in U.S. nursing homes: (1) Those requiring chronic care that enter the facility because they are no longer able to care for themselves at home; and (2) those that usually stay for less than 30 days and are typically admitted following an acute care hospitalization (Abt Associates Inc., 2004). The aim of therapy for chronic care residents is to enhance their quality of life through maintenance of functional ability. The goal of therapy for postacute residents is to enable recovery of functional independence and return to the community (Kochersberger et al., 1994). This article focuses on nursing homes that primarily serve short-stay (postacute care) residents.

Accreditation

The Commission on Accreditation of Rehabilitation Facilities is an independent, nonprofit accreditor of healthcare providers, and networks of various types of rehabilitation programs. In addition to medical rehabilitation programs, CARF also accredits nursing homes along with dementia and stroke care specialty programs. The organization has accredited more than 6000 service providers and is recognized internationally (CARF, 2012a). In 2004, it was estimated that approximately 15.2% of U.S. nursing homes were accredited by independent accreditation organizations (National Center for Health Statistics, 2004), although currently there are only about 250 U.S. nursing homes accredited by CARF (see Table 1 for a breakdown of CARF-accredited nursing homes by state). Compared with nursing homes in the south, those in northeastern states are more likely to be CARF accredited.

Table 1. Number of Commission on Accreditation of Rehabilitation Facilities (CARF)-Accredited Nursing Homes Across U.S. Statesab (n = 246)
StateNumber of nursing homes CARF accredited
  1. a

    A listing of nursing homes across U.S. states was obtained from 2010 OSCAR.

  2. b

    A listing of CARF-accredited nursing homes was obtained from a web search of the CARF website (http://www.carf.org/advancedProviderSearch.aspx).

Delaware 4
Pennsylvania48
Maryland12
Connecticut 9
New Hampshire 3
Virginia10
Oregon 4
Washington 6
Florida17
North Carolina10
Hawaii 1
Ohio20
California25
New Jersey 7
Maine 2
Indiana 8
Tennessee 5
Wisconsin 6
Illinois12
Arizona 2
Massachusetts 6
New York 8
Georgia 4
South Carolina 2
Missouri 3
Colorado 1
Michigan 2
Alabama 1
Texas 4
Oklahoma 1
Kansas 1
Minnesota 1
Iowa 1

Facilities seeking CARF accreditation are required to meet program-specific standards as well as more general organizational standards pertaining to accessibility, information management, performance improvement, and human resources (Robinson, 2005). Standards primarily reflect structure and process aspects of programs and services (DeLisa & Rosenthal, 2005); however, providers are required to measure patient care outcomes as a means of assessing service quality (Robinson, 2005).

Some CARF standards relate to staffing and organizations are required to demonstrate recruitment and retention efforts, maintenance of specific competencies, as well as identification of any trends in personnel turnover (Robinson, 2005). Newer standards place a greater emphasis on risk management, insurance, and performance measurement. These include standards requiring systems for reporting critical incidents, such as medication errors, incidents involving equipment-related injury, communicable disease, and elopement/wandering. Some standards may require written policies and conformance examples, such as medical records, staff and patient interviews, policies and procedures, and documentation (Hare, 2009). In general, organizations are expected to promote patient involvement in care and placement-related decisions (DeLisa & Rosenthal, 2005). It is intended that facilities learn to self-evaluate their practices through the accreditation process (Hare, 2009). Although CARF accreditation demonstrates conformance to internationally accepted standards and a commitment to continuous quality improvement, with few exceptions, accreditation has not conferred any preferred status with payers (DeLisa & Rosenthal, 2005).

Nursing homes volunteer to pay and be inspected by CARF. To receive and maintain accreditation, homes must undergo on-site surveys. These surveys take place every 1–3 years and are conducted by medical rehabilitation specialists currently working in the field (CARF, 2012b; Robinson, 2005). Surveyors generally tour the facility and review documentation, looking for consistency in policies, procedures, protocols, and programs and how these coincide with CARF standards and care outcomes. Patients and families are interviewed to assess how standards are applied. Accreditation is granted based on the existence of quality improvement systems, standards conformance, and positive service outcomes. Facilities must demonstrate 6 months of conformance to be awarded accreditation status. Following accreditation, sites are required to review their practices and submit annual reports (Hare, 2009).

There have been very few studies investigating the impact of CARF accreditation on rehabilitative care processes or outcomes. Mazmanian, Kreutzer, Devany and Martin (1993) surveyed U.S. facilities offering brain injury rehabilitation programs, comparing training and therapy formats between CARF-accredited and nonaccredited facilities (Mazmanian et al., 1993). No differences were noted between accredited and nonaccredited providers, although accredited facilities were more likely than their counterparts to use combined rehabilitation approaches, including one-on-one, group, and home-based therapy (Mazmanian et al., 1993). There have been few studies on accreditation in the nursing home setting although to date mainly positive effects have been observed. Two studies by Lau et al. noted that Joint Commission–accredited nursing homes had fewer inappropriate medication prescriptions (Lau, Kasper, Potter & Lyles, 2004; Lau, Kasper, Potter, Lyles & Bennett, 2005). A study by LTQ Inc. found that accredited facilities had fewer care-related deficiency citations and fewer deficiencies involving immediate jeopardy to residents (Grachek, 2002), whereas Kang, Meng and Miller (2011) observed that residents in accredited nursing homes were less likely to be hospitalized (Kang et al., 2011).

The present study aims to investigate the impact of CARF accreditation on rehabilitative outcomes in nursing homes through examining the postacute care quality measures available as part of Nursing Home Compare. Specifically, we sought to determine whether CARF-accredited facilities demonstrate superior short-stay quality measures; and the characteristics of CARF-accredited nursing homes.

Methods

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Acknowledgments
  7. References

Primary Data

A list of currently accredited nursing homes was identified through a web search of the CARF website (http://www.carf.org/advancedProviderSearch.aspx) in June 2011. Identifying information for all facilities was checked against a complete list of U.S. nursing homes, and all entries that corresponded to other types of facilities (e.g., Veteran's Affairs medical centers, children's convalescent centers) were removed. A total of 246 CARF-accredited nursing homes were identified. Additional primary data used in this investigation included state Medicaid reimbursement levels. These data were previously collected by the authors.

Quality Measures Data

Nursing Home Compare

As quality indicators for the analyses, some of the quality measures for short-stay residents reported on the Nursing Home Compare website were used (www.Medicare.gov/NHCompare). Nursing Home Compare is a web-based report card providing information for all Medicare and Medicaid certified nursing homes. The nursing home quality measures are advantageous for several reasons. They were subject to extensive testing, are derived from the minimum data set (MDS), are readily available, represent measures relevant to both consumers and providers, and the measures used here were developed specifically for short-stay residents (Abt Associates Inc., 2004). Moreover, the quality measures are increasingly being used in empirical research (e.g., Alexander, Lee, Wang & Margolin, 2008).

On-line Survey Certification of Automated Records

The On-Line Survey Certification of Automated Records (OSCAR) contains data collected as part of state/federal nursing home inspections. Facilities that accept residents with Medicare and Medicaid payments are surveyed. This includes most (i.e., 97%) nursing homes in the United States. The survey process occurs approximately yearly and includes the recording of many characteristics of the nursing home (e.g., number of beds) and aggregate characteristics of residents (e.g., number with dementia). The data are commonly used as a secondary source of nursing home characteristics (e.g., Decker, 2008).

Area Resource File

Local economic data on employment and nursing home market concentration were used from the Area Resource File (ARF). The ARF contains information on over 6,000 health, social, and economic indicators for all counties in the United States. (Extensive details regarding this data can also be found on the website www.hrsa.gov.)

Dependent Variables

Five quality measures pertaining to short-stay (postacute care) residents were examined in this research: (1) Percent of short-stay residents given influenza vaccination during the flu season, (2) percent of short-stay residents who were assessed and given pneumococcal vaccination, (3) percent of short-stay residents who have delirium, (4) percent of short-stay residents who had moderate to severe pain, and (5) percent of short-stay residents who have pressure sores. Prior research has identified the latter three quality measures as time sensitive (Castle, Engberg & Liu, 2007). That is, these quality measures can change quickly while other quality measures may develop over a longer period of time (e.g., need for help with daily activities).

In addition to these specific quality measures, we examine the impact of accreditation on quality information from the five-star system. Information from the five-star nursing home quality rating system was used because this system was designed to provide an overall assessment of nursing home quality (CMS, 2011a,b). In this system, each nursing home is rated from 1 to 5 stars in three areas (CMS, 2011a,b). These areas are as follows: health inspections, staffing, and quality measures. The rating symbols are 5 stars (much above average); 4 stars (above average); 3 stars (average); 2 stars (below average); and 1 star (much below average). Information from the health inspections and quality measures was used in this analysis.

The quality measures five-star rating system utilizes 10 of the 19 quality measures (because of the high reliability of these measures) and is based on the most recent three quarters of data reported by nursing homes (CMS, 2011a,b). The health inspection five-star ratings use information from nursing home inspections. Specifically, a deficiency score from up to three inspections and a complaints score from the prior 36 months is used (CMS, 2011a,b).

The rating system is used for reporting on Nursing Home Compare. However, the 5-level rating system is created from a score distribution. The specifications for creating the scores are described in the Design for Nursing Home Compare Five-Star Quality Rating System: Technical Users' Guide (CMS, 2011a,b). The scores for the quality measures (five stars) and scores for the health inspection (five stars) were created for this analysis. These scores range from 0 to 100 and were used here as they represent a more discriminating differentiation between facilities (compared with 5 levels [i.e., stars]). The lower scores indicate higher quality, and 100 indicating the worst quality.

Independent Variables

Table 3 lists the staffing, facility, and market variables that were used in this analysis as independent variables. The variables included in our analyses were derived from prior research in this area that has examined nursing home quality (Castle, Wagner, Ferguson & Handler, 2011). These variables were divided into external, organizational, and internal control variables. The nature of these categories is described further by Castle et al. (2011).

Organizational factors included in this research are Medicaid resident occupancy, size, ownership, chain membership, and occupancy rate. The percent of residents paid for by Medicaid was used as a measure of Medicaid resident occupancy. The number of nursing home beds was used as a measure of size. Two classes of facility ownership were used, for-profit and not-for-profit. Two classes of chain membership were used, chain and nonchain. The occupancy rate is the percent of beds occupied by residents.

Internal factors included in this research are staffing levels of caregivers and resident characteristics (case-mix, psychiatric conditions, mental retardation, and dementia). Three different types of nursing staff were included in the analyses, the number (measured as full-time equivalent [FTE]) of RNs, LPNs, and nurse aides per 100 beds. An average activities of daily living (ADL) score was used to represent case-mix. For each of three ADL questions (eating, toileting, and transferring) in the OSCAR, a score from 0 to 3 was used for no assistance, moderate need for assistance, and high degree of need for assistance, respectively. We then sum these scores, with higher scores indicating a greater average ADL impairment within the facility (Donoghue & Castle, 2009). The numbers of residents with psychiatric conditions and dementia were used to calculate the proportions of residents in each facility with these conditions.

External factors included in this research are Medicaid reimbursement rate, competition, number of elderly in market, and per capita income in the market. The Medicaid reimbursement rate is the average dollar amount (inflation-adjusted) paid by Medicaid in each state per resident day. Competition is measured using the Herfindahl index and represents a measure of the extent of market competitiveness coming from other nursing homes. The county was the market area used in this analysis. This index is calculated by taking each nursing home's percentage share of beds in the county and dividing by the squared market shares of all nursing homes in the county. The number of elderly in a market represents a count of those aged 65 and older per 1000 of the total population in each county, and per capita income in the market represents average income for all residents in a county.

Analyses

Descriptive statistics (means and standard deviations) for the quality of care variables of interest, and for the external, organizational, internal control variables (means, standard deviations, and percents) are presented. The level of colinearity and multicollinearity among the independent variables was determined using the variance inflation factor (VIF) test. The correlation between variables was generally low.

We examined the cross-sectional association of CARF accreditation and quality. Negative binomial regression was used in multivariate analyses to examine the association of accreditation with the quality measures. Quality measures are counts of specific negative events per nursing home, each divided by the number of residents at risk for that negative event. For many facilities, these counts were low or zero. Negative binomial regression is based on a generalization of the Poisson distribution that can account for the skewed nature of data. This allows for more unmeasured heterogeneity among the observations in the sample, which can be manifested when several observations have low or zero events (Gardner, Mulvey & Shaw, 1995).

Given that larger nursing homes have more residents for whom the negative outcomes could occur, the negative binomial regression used the number of residents at risk for each measure as the exposure level for that measure. Coefficients are reported in incident-rate ratio form, which is similar to odds ratios; that is, estimates greater than one represent a positive association between the explanatory variable and the outcome. High values of the quality indicators are associated with lower quality because they indicate a high percentage of residents with the specified negative outcome; thus, coefficients less than one are representative of better quality.

Ordinary least squares (OLS) regression was used to examine the five-star quality measure score and five-star health inspection score. The five-star health inspection score had a skewed distribution; thus, the log transformation was used. This reduced the skewness for this variable and approximated a normal distribution.

To account for possible correlation of outcomes within markets, which can bias the standard errors of the estimates, the Huber-White sandwich estimator (i.e., robust standard errors) clustered by county was also used for all of the multivariate analyses (Zeger & Liang, 1992).

Results

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Acknowledgments
  7. References

The sample consisted of 246 CARF-accredited nursing homes compared with 15,393 nursing homes in the 2010 OSCAR. As shown in Table 2, CARF-accredited homes significantly differed (< .05) from national averages for the quality measures of interest, with the exception of percent of short-stay residents who have delirium, in which there was no difference. The variables describing the independent variables are displayed in Table 3. Several internal, external, and organizational factors of CARF-accredited nursing homes were significantly different from nonaccredited nursing homes. For example, nurse aide staffing was significantly higher. CARF-accredited homes were less likely to be for-profit and admit Medicaid residents.

Table 2. Descriptive Statistics of the Dependent Variables Used in the Analyses
 CARF nursing home sample (= 246)All nursing homes in 2010 OSCAR (= 15,393)
Mean (or%)Standard deviationMean (or%)Standard deviation
  1. a

    Quality Measures Definitions:

  2. 1. “Percent of short-stay residents given influenza vaccination during the flu season” represents the proportion of short-stay residents who received the influenza vaccine (either in the nursing home or outside of the nursing home) during the most recent influenza season in 2010.

  3. 2. “Percent of short-stay residents who were assessed and given pneumococcal vaccination” represents the proportion of short-stay residents whose pneumococcal vaccination status was up to date during the 12-month reporting period in 2010; or were offered and declined the vaccine; or were ineligible for vaccination due to medical contraindications.

  4. 3. “Percent of short-stay residents who have delirium” represents the proportion of short-stay residents at 14-day assessment with at least one symptom of delirium that represents a departure from usual functioning (excluding patients who are comatose, with end-stage disease, or who are receiving hospice care).

  5. 4. “Percent of short-stay residents who had moderate to severe pain” represents the proportion of short-stay residents at 14-day assessment with moderate pain at least daily; or horrible/excruciating pain at any frequency.

  6. 5. “Percent of short-stay residents who have pressure sores” represents the proportion of short-stay residents at 14-day assessment who have either developed at least one stage 1 pressure sore following their day 5 assessment; or whose pressure sore identified at their day 5 assessment has worsened or failed to improve by day 14. RTI International, 2012; Abt Associates Inc., 2004.

  7. b

    5-Star Measures Definitions:

  8. 6. “Quality Measure Score” utilizes 10 of the 19 quality measures from nursing home compare in 2010 (because of the high reliability of these measures) and is based on the most recent 3 quarters of data reported by nursing homes in 2010. The rating system is created from a score distribution ranging from 0 to 100, where lower scores indicate relatively high quality and higher scores indicate relatively poor quality.

  9. 7“Health Inspection Score” utilizes information from nursing home inspections. A deficiency score from up to three inspections and a complaints score from the prior 36 months is used. The rating system is created from a score distribution ranging from 0 to 100, where lower scores indicate relatively high quality and higher scores indicate relatively poor quality. CMS, 2011a, 2011b.

  10. SSR = short-stay resident; CARF = Commission on Accreditation of Rehabilitation Facilities.

  11. c

    < .05.

Quality measuresa
Percent of short-stay residents given influenza vaccination during the flu season (SSR)189%85%c
Percent of short-stay residents who were assessed and given pneumococcal vaccination (SSR) 291%84%c
Percent of short-stay residents who have delirium (SSR)30.8%1%
Percent of short-stay residents who had moderate to severe pain (SSR)415%19%c
Percent of short-stay residents who have pressure sores (SSR)59%12%c
5-star measuresb
Quality measure score (0–100)674.49.969.4c9.6
Health inspection score (0–100)765.26.957.2c6.1
Table 3. Descriptive Statistics of the Independent Variables Used in the Analyses
 CARF nursing home sample (= 246)All nursing homes in 2010 OSCAR (= 15,393)
Mean (or%)Standard deviationMean (or%)Standard deviation
  1. FTE = full-time equivalent; ADL = activities of daily living; RNs = Registered Nurses; LPNs = Licensed Practical Nurses; CARF = Commission on Accreditation of Rehabilitation Facilities.

  2. a

    < .05.

Internal factorsc
Nurse aide staffing (FTEs per resident)0.400.170.31a0.14
LPN staffing (FTEs per resident)0.130.080.110.09
RN staffing (FTEs per resident)0.080.080.080.11
Resident case-mix (ADL score)0.270.090.290.12
Psychiatric condition11%1117%a17
Dementia52%1744%a21
Organizational factors
Medicaid resident occupancy21%2263%a27
Size (number of beds)9981110a74
For-profit ownership4%-63%a-
Chain member53%-53%-
Occupancy rate82%2183%15
External factors
Medicaid reimbursement rate ($)2161.3626132.9033
Competition (Herfindahl Index)3100110432103a2379
Elderly in county (per 1000 population)185302139a371
Per capita income ($)2828904927190a7715

The results of the regression analyses are displayed in Table 4. Regression coefficients for independent variables are also presented. All variables in Table 3 were included in each regression model (results for all variables in the model are available from the authors). Seven models were used examining the short-stay quality measures which included the following: influenza vaccination; pneumococcal vaccination; delirium; pain (moderate to severe); pressure sores; five-star quality measure score; and five-star health inspection score. In the cross-sectional analysis to examine the association of CARF accreditation and quality, all seven quality indicators were associated with CARF accreditation. This supports the hypothesis that CARF-accredited nursing homes are associated with better quality.

Table 4. Regression Coefficients for the Effects of the Commission on Accreditation of Rehabilitation Facilities Accreditation on Nursing Home Quality Indicators
Variables(1)(2)(3)(4)(5)(6)(7)
Percent of short-stay residents given influenza vaccination during the flu season (SSR)aPercent of short-stay residents who were assessed and given pneumococcal vaccination (SSR) aPercent of short-stay residents who have delirium (SSR)aPercent of short-stay residents who had moderate to severe pain (SSR)aPercent of short-stay residents who have pressure sores (SSR)aFive-star quality measure scoreaFive-star health inspection scorea
  1. In columns 1–5, the incident-rate ratio for negative binomial regressions is presented, and for columns 6 and 7, results for ordinary least squares (OLS) regressions are presented. Robust standard errors in parentheses. Regression coefficients are presented for parsimony; all variables in Table 3 were included in each model (results for all variables in the models included in Table 3 are available from the authors).

  2. a

    Variables were coded so that higher scores represent better quality.

  3. CARF = Commission on Accreditation of Rehabilitation Facilities; SSR = short-stay resident.

  4. *< .05; **< .01; ***< .001.

CARF Accreditation0.49***0.31**0.38*0.44***0.24**0.30**0.19**
(0.11)(0.10)(0.13)(0.09)(0.08)(0.11)(0.07)

Discussion

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Acknowledgments
  7. References

In summary, our results would appear to indicate that CARF-accredited nursing homes demonstrate better quality with regard to the short-stay quality measures. This is the first published study, to our knowledge, to examine the impacts of voluntary rehabilitation accreditation on quality measures among short-stay nursing home residents. Given these findings, it is unfortunate that less than 2% of nursing homes are CARF accredited.

The demand for rehabilitative care in this setting has been steadily increasing (Wells, Seabrook, Stolee, Borrie & Knoefel, 2003); thus, this research is both timely and of great importance. Some scholars have suggested that better policies from the Centers for Medicare and Medicaid Services (CMS) could be designed to make accreditation more affordable for nursing homes (Brasure, Stensland & Wellever, 2000). This is especially true for nursing homes caring for significant proportions of short-stay residents. Demand is primarily driven by decreasing hospital lengths of stay for older patients with disabling conditions, following implementation of the acute care prospective payment system (Morrisey et al., 1988). This shift in the setting of rehabilitative care has also been facilitated by the Medicare SNF benefit, which covers postacute rehabilitation to enable recovery of functional independence (Buntin et al., 2005). Greater demand for nursing home-based rehabilitation is expected to continue as skilled nursing facilities become more accepted as comparable and less expensive alternatives for patients with postacute rehabilitation needs (Sahyoun, Pratt, Lentzner, Dey & Robinson, 2001).

During a nursing home rehabilitative stay, minimizing iatrogenic complications is paramount to improve the client's probability of discharge. For example, pneumococcal and influenza vaccination are important measures of quality, as nursing home residents are particularly vulnerable to such infections, which are responsible for over 33,000 deaths in Americans aged 65 and older yearly (Arden, 2000; Marrie, 2002; Robinson et al., 2001; Thompson et al., 2003). Previous studies suggest that vaccination rates for these illnesses in nursing homes are well below what has been recommended by the federal Advisory Committee on Immunization Practices (Bardenheier, Shefer, McKibben, Roberts & Bratzler, 2004; CDC, 2008a; CDC, 2008b). Development of common concerns during a rehabilitative stay such as pain, delirium, or pressure ulcers can further impact the rehabilitation potential of older adults. This research supports that CARF-accredited homes are better performers in minimizing these events, which ultimately can result in better outcomes.

Our recent research examining The Joint Commission–accredited homes support the findings of this study with The Joint Commission-accredited homes reporting better quality measures (Wagner, McDonald & Castle, 2012a), fewer deficiency citations (Wagner, McDonald & Castle, 2012b), and improved patient safety culture (Wagner, McDonald. & Castle, 2012c). Our findings with respect to differences between CARF-accredited and nonaccredited nursing homes are also consistent with this prior research among nursing homes accredited by The Joint Commission. Several internal, external, and organizational factors of CARF-accredited nursing homes were significantly different from nonaccredited nursing homes. For example, nurse aide staffing was significantly higher. CARF-accredited homes were also less likely to be for-profit and admit Medicaid residents. Higher revenues from greater private-pay occupancy of residents may increase the amount of financial resources to devote to accreditation.

As lack of financial resources may be the single barrier to seek voluntary accreditation, providing incentives to encourage nursing homes to seek accreditation is recommended. For example, the Ontario Ministry of Health and Long-Term Care provides financial incentives to nursing homes that are voluntarily accredited above and beyond what is necessary to maintain licensure (Ontario Ministry of Health & Long-Term Care, 2011). Further research that examines the impact of financial incentives to encourage nursing home voluntary accreditation and its ultimate impact on marketing strategies as well as rehabilitation care outcomes such as discharge disposition are needed.

This study is not without limitations. First, we did not include any of the long-stay quality measures in our analysis given the focus of CARF on short-stay rehabilitation. Despite this, we recognize that long-stay quality measures such as falls; losing control of bowel and bladder; and residents who are restrained, needing help with activities of daily living, and presence of urinary catheters are equally important to monitor. Although this research examined only the short-stay variables as a measure of quality of care, variables such as discharge status (e.g., to home) were not included in our model. Finally, although no differences in overall RN staffing levels were noted between accredited and nonaccredited facilities, there may have been differences in certified rehabilitation registered nurse (CRRN) levels that we were unable to detect because CRRN staffing was not examined in this study.

In conclusion, approaches beyond traditional regulation and government inspection are necessary to include the quality of nursing home care. This study supports the fact that voluntary accreditation improves the quality of care in short-stay residents residing in CARF-accredited facilities. Further research into the cost and benefits of voluntary accreditation are necessary in order for CMS and policy makers to support this as an approach to improve nursing home quality.

Acknowledgments

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Acknowledgments
  7. References

Supported in part by an Agency for Healthcare Research and Quality grant, 1 R03 HS013983-01A1. University of Pittsburgh Institutional Review Board. IRB Number: 0612069.

Key Practice Points
  • The demand for rehabilitative nursing care in nursing homes has gradually increased. Greater demand for high-quality rehabilitative services is expected as nursing facilities become more acceptable alternatives for patients with postacute rehabilitative needs.
  • Nurses are a key player in their work setting to ensure that standards for quality rehab care are met. These include ensuring that nursing home residents are vaccinated against influenza and pneumococcal pneumonia; assessment and timely treatment of pain; and prevention of delirium and pressure sores.
  • There are a number of benefits associated with voluntary accreditation of a healthcare facility including improving performance and quality of care provided.
  • This research supports that CARF-accredited nursing homes are better performers in minimizing iatrogenic effects, which can ultimately results in better outcomes of care.
Earn nursing contact hours

Rehabilitation Nursing is pleased to offer readers the opportunity to earn nursing contact hours for its continuing education articles by taking a posttest through the ARN website. The posttest consists of questions based on this article, plus several assessment questions (e.g., how long did it take you to read the articles and complete the posttest?). A passing score on the posttest and completing of the assessment questions yield one nursing contact hour for each article.

To earn contact hours, go to www.rehabnurse.org and select the “Education” page. There you can readthe article again, or go directly to the posttest assessment by selecting “RNJ online CE.” The cost for credit is $10 per article. You will be asked for a credit card oronline payment service number.

Contact hours for this activity are available at no cost to ARN members for 60 days following the date the CE posttest is first available, after which time regular pricing will apply. The contact hours for this activity will not be available after August 31, 2015.

The Association of Rehabilitation Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation (ANCC-COA).

References

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Acknowledgments
  7. References