Long-term Care and Patient Safety

Background
The patient safety field has primarily focused on improving safety in hospital
and ambulatory settings. Yet a large and growing number of Americans who
do not require hospital-level care but are unable to be safely cared for at home
reside in settings referred to as long-term care. These settings include skilled
nursing facilities (SNFs), inpatient rehabilitation facilities, and long-term acute
care hospitals. There were more than 1.6 million residents of SNFs in 2011,
and long-term acute care hospitals admissions among Medicare beneficiaries
have more than doubled over the past 15 years.
Patients in long-term care settings may be particularly vulnerable to safety
problems in the course of their care. Patients requiring care in long-term care
facilities are disproportionately older and chronically ill, and they often enter
long-term care after an acute hospitalization. Health care utilization after
entering long-term care is high—a study by the Office of the Inspector General
(OIG) found that nearly 25% of Medicare SNF residents require hospitalization
each year.

Each type of long-term care setting provides different services and is suitable
for different types of patients:

 Long-term acute care hospitals care for medically complex patients expected to
require care for weeks to months. These patients are often chronically critically ill,
most commonly recovering from a hospitalization that included an intensive care unit
stay. These facilities provide services very similar to acute care hospitals, including the
ability to care for patients requiring mechanical ventilation, complex wound care, or
hemodialysis. The facilities may be freestanding or attached to an acute hospital, and
they are subject to the same licensing and credentialing requirements as traditional
hospitals. Patients at long-term acute care hospitals generally require daily evaluation
by a physician.
 Inpatient rehabilitation facilities care for patients recovering from surgery,
trauma, or an acute illness. They provide intensive rehabilitation—patients must be
able to tolerate 3 hours of physical or occupational therapy daily—with the goal of
 restoring patients to their premorbid functional status. Care is overseen by a
multidisciplinary team that includes a physician, typically a specialist in rehabilitation
medicine.
 Skilled nursing facilities generally care for patients who may be chronically ill
but are considered medically stable. In general, these patients do not require daily
evaluation by a physician but do require services such as physical therapy or wound
care.

Patients often enter long-term care after an acute hospitalization. Data from
2011 indicates that nearly 40% of Medicare beneficiaries are discharged to
some form of long-term care facility—most often a SNF—after hospital
discharge. Therefore, the term postacute care is also used to refer to the
utilization of long-term care facilities to provide continuing care after
hospitalization. Postacute patients represent an increasing proportion of the
overall SNF patient population, and these patients—who are often medically
complex and frail—may tax the ability of SNFs to provide safe care. As a result
of all these factors, the safety field is starting to examine and address safety
issues faced by patients in long-term care.

Safety Concerns in Long-term Care

Preventable adverse events are common in long-term care. A 2014 report by
the OIG found that 22% of Medicare beneficiaries in SNFs experienced an
adverse event during their stay, half of which were preventable. More than half
of the patients who experienced an adverse event at a SNF required
hospitalization. A separate OIG report found an even higher incidence of
adverse events at rehabilitation facilities. Among these are hazards that are
well documented in older patients, such as medication errors, health care–
associated infections, delirium, falls, and pressure ulcers. Adverse drug events
were the most common type of adverse event in the OIG study as well as in
other studies of long-term care populations. While patient complexity explains
some of these events, it is also worth noting that computerized provider order
entryand other medication safety strategies have not been implemented as
widely in SNFs as in hospitals. Health care–associated infections—particularly
catheter-associated urinary tract infections—are also common in long-term
care, and efforts are underway to address this problem. A WebM&M
commentary discusses the types of adverse events that occur in SNF patients
in more detail and gives evidence-based recommendations for preventing
these harms.
Establishing a robust culture of safety is essential for minimizing patient harm.
Unfortunately, safety culture in many long-term care facilities is poorer than
that found in hospitals and ambulatory clinics. A 2006 study using the AHRQ
Hospital Survey on Patient Safety Culture found that nursing home
administrators perceived safety culture in their facilities to be lower than
hospital benchmarks across nearly all domains of the survey. AHRQ
subsequently developed a safety culture survey instrument for nursing
homes and has released biannual benchmarking data since 2008. The most
recent (2014) data indicates overall improvement in long-term care safety
culture, but respondents still raise concerns about potential patient harm due to
inadequate staffing and an overly punitive culture.

Current Context
Improving safety in long-term care facilities will require research into the safety
problems faced by patients, education and training of health care providers in
long-term care settings, system-level interventions to enhance care
coordination, and greater incentives for long-term care facilities to prioritize
patient safety.

The federal government is leading many efforts to improve the safety and
quality of care at long-term care facilities. The Center for Medicare and
Medicaid Services (CMS) Nursing Home Compare website allows patients and
providers to compare long-term care facilities on various quality metrics,
including measures of patient safety (such as the proportion of patients who
experience a health care–associated infection). CMS has also proposed
new revisions to long-term care facilities' conditions of participation in the
Medicare and Medicaid programs, which explicitly emphasize a focus on
ensuring the quality of care for long-term care facility residents. AHRQ is
funding research to examine the epidemiology of adverse events in long-term
care settings and identify effective preventive strategies. AHRQ has also
developed a number of resources to examine and address safety in long-term
care, including training programs for staff, an ongoing collaborative program to
prevent catheter-associated urinary tract infections, and a guide to help nursing
homes appropriately use antibiotics.
The Joint Commission offers accreditation programs for nursing care centers
that provide postacute care services. These include SNFs and most inpatient
rehabilitation facilities. The accreditation process emphasizes the importance
of patient safety and efforts to prevent hospital admissions among long-term
care patients. The Joint Commission National Patient Safety Goals for long-term
care facilities were updated in 2016. These require SNFs to have measures in
place to prevent specific clinical harms (such as falls, pressure ulcers, and
health care–associated infections) and to conduct medication reconciliation.
Long-term acute care hospitals and inpatient rehabilitation facilities are
accredited in the same fashion as acute care hospitals, and they are subject to
the same National Patient Safety Goals (which were also updated in 2016).
While these efforts are important (and are beginning to bear fruit), fundamental
health care system issues must be addressed in order to improve safety in
long-term care. As discussed in a 2015 WebM&M commentary, neither
hospitals nor long-term care facilities are incentivized to improve care
transitions under the current prospective payment system. CMS is developing
novel care models and payment systems to encourage health care systems to
prioritize safe care transitions between different types of facilities. Although the
data on these new models—which include accountable care organizations,
bundled payments for specific diagnoses, and financial penalties for hospitals
with high readmission rates—is still preliminary, there are early indications that
health care systems are shifting their orientation toward caring for patients
across the continuum of care rather than in single episodes.