Long-Term Care Administration: Quality, Ethics & Aging

Staff Engagement Models in Long-Term Care

Long-term care refers to the wide range of medical activities designed to assist people living with chronic health issues. Debates concerning hospital quality and nursing care often occur independently of one another. The activities that ensure adequate performance of hospital nursing play a role in quality improvement and the realization of effective cost control. Nursing home practitioners are critical to the provision of quality and efficient care. Facilities that adopt front-line staff-driven performance improvement approaches — such as Transforming Care at the Bedside — demonstrate how practitioners, driven by effective leadership, can improve both the quality and efficiency of hospital care (Needleman, 2009).

Healthcare organizations may adopt strategies and approaches to improve the provision of quality care, with particular emphasis on the engagement of front-line staff. The Transforming Care at the Bedside (TCAB) model is one that nursing homes should embrace. Its primary objective was to engage front-line staff and nursing leadership to improve the quality and safety of care by creating a high-quality work environment that attracts and retains nurses — who in turn improve the experience of care for patients and their families. Numerous organizations that utilized the TCAB program successfully engaged front-line staff and subsequently initiated changes that improved unit processes, thereby improving the quality of care (Needleman, 2009).

The Care Transitions Coordinator (CTC) program, on the other hand, facilitated physician engagement for homecare and hospice healthcare facilities. Physician engagement provides for patient follow-up with their physician within one week of discharge on a regular basis. This practice also helps reduce re-hospitalizations, representing a significant step toward improving care quality. The CTC program is relationship-based, with the coordinator serving as a central point for sharing information among all individuals engaged with the patient. However, the program requires cooperation among physicians and other healthcare practitioners to achieve its objectives. Research indicates that the primary outcome of this program was a decrease in re-hospitalization rates, and it also enhanced the physician-patient relationship, contributing to improved quality of care (Fleming, 2013).

There is a notable similarity between the CTC and TCAB programs: both play a role in staff management. Although they are not the only models with the capacity to increase staff engagement, they have proved to offer substantial help in improving the quality of care in nursing homes and homecare facilities. Scholars have examined how policies influence the quality of care in nursing and homecare, and the government has a clear role to play in financing long-term care — particularly for retiring elderly individuals and economically disadvantaged members of society (Fleming, 2013). States must also continue to integrate acute and long-term care services for the elderly in order to contain spending.

Financing and Policy Considerations

The financing of long-term care remains a critical policy area. In the United States, for example, Medicaid offers lower payment rates compared to private insurance, making it a more accessible but constrained option for many patients. Hospitals also have a role to play in implementing policies that work in tandem with programs such as TCAB and CTC. When hospitals integrate their operations to improve the quality of care, this increases efficiency in care provision. Therefore, organizations, nurses, and other key stakeholders must embrace such policies. Organizations will also need to value the contributions of their staff and shift their institutional vision from viewing nursing as a cost center to recognizing it as a critical service line (Fleming, 2013).

Ethical Issues in Long-Term Care Settings

Ethical issues have long been part of the healthcare field. In recent years, there has been increased examination of ethical issues specific to the long-term care setting. In nursing homes, practitioners must navigate care for a diverse patient population, including those with Alzheimer's disease, by instituting ethical decision-making frameworks suited to extended-stay environments. Unlike acute hospital settings, long-term care facilities deal with a wide variety of patients who often suffer from severe and complex cases (Goldsmith, 1993).

Many residents experience reduced mental capacity; therefore, decisions concerning autonomy and related issues must account for individual differences rather than applying simple categorical judgments about whether a resident has or lacks adequate decision-making capacity (Goldsmith, 1993). Practitioners invest significant effort in involving patients in care-related decisions, though they frequently encounter conflicts with patient preferences. Patients are expected to comply with treatment plans even in the absence of a care practitioner. For instance, a plan may require adherence to a restrictive diet because certain foods are harmful, but encouraging patients to comply and refrain from desired foods presents an ongoing challenge (Pratt, 1999).

Denial is another ethical issue significant to long-term care. Patients often show reluctance to accept a terminal diagnosis, and this becomes an ethical concern because it affects how practitioners address impending death and the decision to accept long-term care (Pratt, 1999). There is also considerable variation in access to long-term care services from state to state, between urban and rural settings, and even within regions. To the degree that access to proper care is considered a right, unequal access qualifies as an ethical issue. When long-term care staff suspects that a patient is not safe at home due to neglect or abuse, this also presents an ethical dilemma.

In such cases, staff must protect the welfare of the patient without making unfounded accusations. If their concerns are substantiated, they have an ethical obligation to report the matter to the appropriate authorities (Pratt, 1999). Nursing homes are increasingly focused on reinforcing ethical decision-making and are working to redefine ethical guidelines to fit the long-term care context (Goldsmith, 1993). As a result, they are developing strategies, rules, procedures, and educational programs to assist families and staff in making sound ethical determinations in cases of dilemmas.

References

Fleming, O. M. (2013). Improving patient outcomes with better care transitions: The role for home health. Cleveland Clinic Journal of Medicine, 80(1). doi: 10.3949/ccjm.80.e-s1.02

Goldsmith, S. B. (1993). Long-term care administration handbook. Gaithersburg, MD: Aspen Publishers.

Joseph, A. (2006). Health promotion by design in long-term care settings. The Center for Health Design. Retrieved November 27, 2013, from

Knickman, R. J., & Snell, K. E. (2002). The 2030 problem: Caring for aging baby boomers. Health Services Research, 37(4), 849–884. doi: 10.1034/j.1600-0560.2002.56.x

Needleman, J. (2009). The role of nurses in improving hospital quality and efficiency: Real-world results. Health Affairs, 28(4), 625–633.

Pratt, J. R. (1999). Long-term care: Managing across the continuum. Gaithersburg, MD: Aspen Publishers.