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.
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)
|State||Number of nursing homes CARF accredited|
|New Hampshire|| 3|
|New Jersey|| 7|
|New York|| 8|
|South Carolina|| 2|
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.