REPORT: Progress on Implementation of ACA Nursing Home Provisions Examined

The Kaiser Commission on Medicaid and the Uninsured released a report in January that examines the Centers for Medicare and Medicaid Services‘ (CMS) progress on the implementation of multiple provisions in the Affordable Care Act (ACA) that are intended to improve nursing home transparency, care quality, and abuse prevention. Though overall, the researchers give CMS good marks for implementation, several key provisions designed to improve transparency and address gaps in training are behind schedule.

Reporting System for Nurse Staffing Delayed

Nursing homes are mandated to report accurate information on nurse staffing, including direct-care staff. Nurse staffing information is considered an “important quality indicator” and included in CMS’s Nursing Home Compare, the report explains. The minimum nurse staff level of 4.1 hours is required to receive the highest rating.

However, self-reported nurse staffing information is “not reliable,” a 2001 Health and Human Services study found. To address this problem, HHS recommended establishing a system to collect staffing data using “auditable and verifiable sources such as payroll records, temporary agency contracts, and cost reports.”

In addition to improving the accuracy of Nursing Home Compare, the new reporting system would also allow CMS to develop quality measures based on staff turnover and retention rates, the authors write.

An ACA provision imposed a March 2012 deadline to establish the long overdue nurse staffing reporting system, the report explains. When completed, the new system would provide nursing homes with “a uniform format” to report “total number of residents, resident case mix, turnover and retention rates, and daily hours of care provided by each direct-care employee category for both regular and contract employees.”

However, citing “workload and costs,” in December 2011, CMS said that this requirement would not be met for two or three more years.

Culture Change and Dementia Training

The ACA also authorized a demonstration project to develop best practice resources to improve resident care through culture change. The authors note, however, that no funds have been allocated to this demonstration project to date.

The law also mandates that nursing assistants be trained in dementia care and abuse prevention as part of the basic 75 hours of training required for aides who work in Medicare- and Medicaid-certified facilities. Under the law, such training could also be required by HHS as part of in-service training.

“Hand in Hand,” the CMS curriculum introduced in April 2012 to address the misuse of antipsychotic drugs to sedate and chemically restrain nursing home residents with dementia, is a major step toward improving nursing assistant training, the authors report. However, they argue, the curriculum’s effectiveness may be limited if it is used as part of the basic training requirement rather than to supplement it. Additionally, “high turnover creates a continuing challenge” to maintain a trained direct-care workforce, they note.

“The Implementation of Affordable Care Act Provisions to Improve Nursing Home Transparency, Care Quality, and Abuse Prevention” was prepared for the Kaiser Commission on Medicaid and the Uninsured by Janet Wells, a long-term care consultant, and Charlene Harrington, of the University of California, San Francisco.

— by Deane Beebe