1. Caregivers ARE Quality in Long Term Care Christine T. Kovner, R.N., Ph.D. Division of Nursing, Steinhardt School of Education, NYU April 30, 2003

2. Total Nurse Staffing Hours per Resident per Day, 2001 Certified nurse aides (CNA)- 2.1 hours Licensed practical/vocational nurse (LPN/LVN) - 0.7 hours Registered nurses (RN) – 0.7 hours Only RN hours have increased from 0.4 hours per day in 1993, while acuity has increased Harrington from CMS OSCAR data

3. Reported Staff Ratios on each Shift – Nursing Homes 2001 Reported Staff Ratios on each Shift – Nursing Homes 2001 1 CNA to 11.8 Residents 1 CNA to 11.8 Residents 1 LVN/LPN to 34 Residents 1 LVN/LPN to 34 Residents 1 RN to 32 Residents 1 RN to 32 Residents Harrington from CMS OSCAR data

4. Research Studies: Positive Relationship Between Licensed Nurses & Quality Increased licensed nursing hours were related to improved functional ability and decreased probability of death Increased licensed nursing hours were related to improved functional ability and decreased probability of death Facilities with higher nurse staffing levels have fewer deficiencies Facilities with higher nurse staffing levels have fewer deficiencies Facilities with more RNs per LPN had fewer assessment deficiencies Facilities with more RNs per LPN had fewer assessment deficiencies Bliesmer et al., 1998; Harrington et al., 2000; Moseley & Jones, 2003

5. Research Studies: Positive Relationship Between Licensed Nurses & Quality Nursing homes meeting HHS preferred minimum staffing levels had no violation that caused actual harm to patients Nursing homes meeting HHS preferred minimum staffing levels had no violation that caused actual harm to patients 68% of homes that did not meet HHS standards had such violations 68% of homes that did not meet HHS standards had such violations Less than 2.0 hours of nurse aid care per nursing home resident were almost 4 times more likely to get pressure sores than those in nursing homes that provided more than 2 hours Less than 2.0 hours of nurse aid care per nursing home resident were almost 4 times more likely to get pressure sores than those in nursing homes that provided more than 2 hours (Stark report, 2001); (DHHS Report to Congress: Appropriateness of Minimum Nursing Staffing Ratios in Nursing Homes, 12- 1 (Spring 2000).

6. Medication Errors in Home Care for Patients 65 years and older 1.4% of patients taking medications older adults should always avoid 1.4% of patients taking medications older adults should always avoid 8.4% of patients taking medications rarely appropriate for older adults 8.4% of patients taking medications rarely appropriate for older adults Kovner, Menezes, & Feldman, 2003; MEPS data from AHRQ

7. Occupational Training Requirements Many believe minimum training for nursing assistants should be increased: Nursing Assistants --75 hours Nursing Assistants --75 hours Manicurists -- 400 hours Manicurists -- 400 hours Barber -- 1500 hours Barber -- 1500 hourswww.barbercosmo.ca.gov/

8. Recommended Nursing Hours in NHs (direct and indirect) Registered Nurses 69 minutes (1.15 hours) per day Licensed practical/ vocational nurses 42 minutes (.70 hours) per day Nursing assistants 162 minutes (2.7 hours) per day Total Nursing 273 minutes (4.55 hours) per day Harrington, C., Kovner, C., et al. (2000). Experts recommend minimum nurse staffing standards for nursing facilities in the U.S. The Gerontologist 40, 5-16.

9. Geriatric Preparation Less than <1% (21,500) of working RNs are certified in geriatrics Less than <1% (21,500) of working RNs are certified in geriatrics Fewer than 0.3% (333) of the 97,362 physician residents slots are for geriatrics Fewer than 0.3% (333) of the 97,362 physician residents slots are for geriatrics Only 0.3% (720) of 200,000 pharmacists have geriatric certification Only 0.3% (720) of 200,000 pharmacists have geriatric certification Kovner, C.T., Mezey, M., & Harrington, C. (2002).

10. References Anderson, R. A., Hsieh, P., Su, H. (1998). Resource allocation and resident outcomes in nursing homes: Comparisons between the best and worst. Research in Nursing and Health, 21, 297-313. Kovner, C.T., Menezes, J. & Feldman, P. (2003). Paper in progress. Harrington, C., Kovner, C., Mezey, M., Kayser-Jones, J., Berger, S., Muhler, M., Reilly, K., Burice, R., Zimmerman, D. (2000). Experts recommend minimum nurse staffing standards for nursing facilities in the U.S. The Gerontologist 40, 5-16. Kovner, C.T., Mezey, M., & Harrington, C. (2002). Who cares for older adults? Workforce implications of an aging Society. Health Affairs 21(5), 78-89. Bliesmer, M. M., Smayling, M., Kane, R. & Shannon, I. (1998) The relationship between nursing staffing levels and nursing home outcomes. Journal of Aging and Health, 10(3), 351-371. Harrington, C. Zimmerman, D., Karon, S. L., Robinson, J. & Beutel, P. (2000). Nursing home staffing and its relationship to deficiencies. Journal of Gerontology: Social Sciences, 55B(5), S278-S287. Linn, M. G., L. & Linn, B. A. (1977). Patient outcomes as a measure of quality of nursing home care. American Journal of Public Health. 67(4), 337-344. Nyman, J. A. (1988). Improving the quality of nursing home outcomes: Are adequacy or incentive-oriented policies more effective? Medical Care, 26(12), 1158-1171. Kayser-Jones, Wiener, C. L. & Barbaccia, J. C. (1989). Factors contributing to the hospitalization of nursing home residents. The Gerontologist, 29, 502-510. Spector, W. D., & Takada, H. A. (1991). Characteristics of nursing homes that affect resident outcomes. Journal of Aging and Health 3(4), 427- 454. Cherry, R. L. (1991). Agents of nursing home quality of care: Ombudsman and staff ratios revised. The Gerontologist. 31, 302-308. Kayser-Jones, J. & Schell, E. (1997). The effect of staffing on the quality of care at mealtime. Nursing Outlook, 45(2), 64-72. Harrington, C., Carrillo, H., Thollaug, S., & Summers, P. (1999)Nursing facilties, staffing, residents, and facility deficiencies 1991-1997. (Report prepared for the Health Care Financing Administration. San Francisco: University of California.