Care Home Standards:When big is not better

The Care Home market in the UK has seen a significant move over recent years towards the consolidation of ownership into the hands of fewer and larger ownership organisations. While in financial terms this may make sense there has been concern among commissioners and regulators whether these larger corporate organisations are always delivering a better quality of care in their homes in comparison to the smaller or single single home providers that are becoming a less significant part of the market.

Much of the concern about the standards in the Care Homes provided by the "big players" has admittedly been anecdotal and we are not aware that there has been any systematic study of this in the UK. Nevertheless the anecdotal evidence seems quite strong and it has been interesting to speculate why these larger organisations sometimes do not match the quality of care in smaller scale provider organisations.

Now a study by the University of Michigan School of Public Health suggests that the very strengths of the larger nursing home chain- its ability to standardize and perfect administrative practices throughout the chain-may also be the very thing that hurts patient care. While the study was confined to the more Nursing Home oriented facility in the US, it may have important lessons for the delivery of care across the Care Home sector.

"Consumers need ways to identify what is a good or bad nursing home when making choices about where to place a loved one," said Jane Banaszak-Holl, corresponding author on the study. "Right now, we have an easier time distinguishing the quality in McDonalds versus Boston Market than we have distinguishing how, for example, a Sun-owned nursing home differs from a Beverly Enterprises nursing home."

As in the UK these larger chain-owned nursing homes are the predominant type of institutional care in the United States. Studies in the US have shown that care in chain-owned nursing homes is generally not as good as care in nonprofit and singly-owned nursing homes.

"If they (chain-owned nursing homes) are really not as good, we need to think about how to improve them," said Akiko Kamimura, a U-M doctoral student in Health Management and Policy at the School of Public Health, and first author of the study.

The study suggests that corporate standardization of clinical and facility processes improved resident care, but that corporate standardization of administrative processes hurt patient care. The study concluded that chains need to balance administrative efficiency with the local needs of the individual chain-owned facilities to optimize the quality of their patient care.

The researchers surveyed 203 nursing homes in Michigan and North Carolina and looked at the effects of corporate standards and training in three areas: administrative processes, clinical processes, and facility design. The study examined the impact on the total number of health deficiencies given to facilities on state inspections, and the percentage of residents with bedsores. An example of a health deficiency would be inserting a catheter unnecessarily because it makes care easier.

An example of standardizing administrative processes would be to share common marketing materials. An example of facility standardization would be to use the same facility layout, and an example of standardizing clinical processes might be to implement guidelines for the treatment of resident bedsores throughout the chain.

"Standardization is a way to think about changing service delivery across many areas, including administrative and clinical processes and even within facility layout," said Banaszak-Holl. Chains that over-emphasize administrative processes don't take advantage of how much their staff can learn---and ultimately improve patient care---from the shared knowledge of developing protocols for handling resident needs.

"What we have stressed in the larger project is that chain ownership is not necessarily bad for the quality of health care, Banaszak-Holl said. "What is problematic is a shift away from community values and local needs, and an overly strong emphasis on administrative rather than clinical outcomes. A good corporate chain can implement a set of practices that still attends to local needs and resident outcomes while introducing greater economies of scale and better business practices."

The study, "Do corporate chains affect quality of care in nursing homes" The role of corporate standardization" appears in Health Care Management Review.

Dementia: Research supports person centered care

An intensive comparative study of two nursing home units using contrasting approaches to dementia care for elders with severely disturbed behaviors has shown that "humanizing" approaches to dementia care may not only extend quality of life for patients, but also their length of life.

Central Michigan University professor of anthropology Athena McLean in her recently published book, "The Person in Dementia: A Study of Nursing Home Care in the U.S.," demonstrates the very different outcomes of two approaches to dementia care: a rigid task-oriented maintenance approach which placed emphasis on disease progression and a flexible person-centered approach which focussed on the older persons communication and individual needs.

There were dramatic differences in patient quality of life at the two nursing units.

Patients at the person-centered unit, where staff looked beyond physical and reasoning abilities to the person's will and relationship with others, were happier, had improved quality of life and lived longer.

Those at the unit which focussed on disability and pathology tended to have personal needs ignored, were heavily medicated and often failed to thrive.

"These findings address issues that medicine can't answer," said McLean. "They are valuable not only for improving the general quality of life for these elders, but also for the long-term outcome based on how they are treated and cared for. These elders require attention, time and a lot of caring interaction."

The study also showed that relations among professional and administrative staff within a service can significantly affect the quality of the dementia care elders receive.

According to McLean; "Good caregivers are leaving the profession because they are underpaid and unappreciated. It needs to be understood by policy makers, family members and clinicians alike that money needs to be put into retaining quality caregiving staff, instead of only fancy facilities, which is currently the trend."

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