Raising Expectations: A State Scorecard on Long-Term Services and Supports for Older Adults, People with Physical Disabilities, and Family Caregivers
Preventing hospitalizations
Another indicator of LTSS quality, both in nursing homes and among home health patients, is the rate of hospitalizations. People who are receiving appropriate primary care and whose medical care is well coordinated with other services and supports should have fewer hospitalizations. States that do a better job of monitoring the quality of nursing home and home health care will reduce unnecessary hospital stays and, thus, achieve lower costs. The Scorecard finds that the bottom-performing states had, on average, three times the rate of hospitalization of long-stay nursing home residents compared with the top states: 29 percent compared with 10 percent.
Better quality of care can be cost-effective as well. For example, there is a strong correlation between occurrence of pressure sores and hospital admissions among long-stay nursing home residents (see Exhibit 15, p. 48). This finding is important for two reasons. Pressure sores are preventable with high quality of care and can result in serious, life-threatening infections in people who develop them. In addition, transitions between settings (e.g., nursing home to hospital), especially those that are caused by poor quality care, are both costly and often traumatic for LTSS users and their family caregivers. Though the variation is less dramatic, hospitalization rates among home health patients in the bottom five states averaged 37 percent, compared with 23 percent among the top five states.
Policy action: Some states are beginning to develop more coordinated service delivery systems that integrate primary, acute, chronic, and long-term services. Integrated approaches such as the Program of All-Inclusive Care for the Elderly (PACE) have a proven record of improving outcomes and reducing the use of institutions.
Nurse delegation
State Nurse Practice Acts usually determine the extent to which direct care workers can provide assistance with a broad range of health maintenance tasks.4 For this Scorecard, we asked the National Council of State Boards of Nursing about state practices in delegating 16 specific tasks, including administration of various types of medications, ventilator care, and tube feedings. The five top-performing states allowed all 16 tasks to be delegated, whereas the bottom six states allowed none to be delegated. The median number of tasks that states allowed nurses to delegate was 7.5. Lower ranked states can learn from the top performers that delegation of these tasks to direct care workers is possible and supports consumers' choice to live in homelike settings.
Policy action: State policy directly determines what health-related tasks can be delegated. Unlike some policy changes that may cost states money and are therefore more challenging to implement, changing nurse practice laws will, if anything, save money in public programs by broadening the type of workers who can safely perform these tasks.