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Twenty years of OBRA—Has it really been that long?

August 1, 2008
by root
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Healthcare has had a long history of self-improvement. One need look no further than the Flexner Report (published in 1910) and the dramatic changes it precipitated in American medicine. Or the creation in 1951 of the Joint Commission on the Accreditation of Hospitals (a product of the American Hospital Association, the American Medical Association, the American College of Physicians, and the American College of Surgeons). These were phenomena initiated from within the professions, not forced on the professions from without.

The scandals that precipitated them were, it is true, far more newsworthy than much of what bedeviled nursing homes in the late 1980s. Flexner, for example, described Chicago's 14 medical schools as “a disgrace to the State whose laws permit its existence…indescribably foul…the plague spot of the nation.” Hospitals had their own scandals. And, given that history, one might argue that the involved professions had no choice but to act. But, the point is, they did.

And nursing homes didn't—even as scandals and exposés about poor-quality care, abuse, and fraud in nursing homes became depressingly common. I write these words not to disparage nursing homes. I am well aware of the incredible work performed by the overwhelming majority of nursing home operators under the most difficult circumstances. It was a distinct privilege to represent them in Washington for well over 15 years. Those are some of my proudest and most gratifying moments in a long career in gerontology.

Rather, my point is to learn from the past and to help others in our profession avoid the mistakes made by all of us in the 1980s. Most of my readers are well aware of my favorite and oft-repeated quotation attributed to Spanish-born philosopher George Santayana: “Those who cannot learn from history are doomed to repeat it.” The lessons of the Omnibus Budget Reconciliation Act of 1987 (OBRA '87), our own reform legislation, are 20 years later still there for all our educations.

Let's start with the standards themselves. This is the one area where we might well have taken the lead. The Institute of Medicine's 1986 report on “Improving the Quality of Care in Nursing Homes” was both groundbreaking and mundane—mundane in that so few of its 100-plus recommendations were either revolutionary or even objectionable. They included suggestions for a minimal amount of nurse staffing, training for nursing aides, mandated resident assessments, and annual reviews.

It was groundbreaking, however, in that it took such a report and a subsequent act of Congress to make them a recognized part of nursing home culture.

In fact, when one reflects on the legislation, its most surprising feature was that it was even deemed necessary. Who in long-term care can argue the point that progress along the continuum must of necessity begin with an examination of resident needs and the corresponding development of a reflective plan of care? Who can dispute the need for nurses in a nursing home? Or that aides should undergo at least 75 hours of training before caring for their frail and needy charges?

We couldn't and, to our credit, we didn't. The American Health Care Association's (AHCA) objections dealt more with practical realities than with the substantive recommendations. A requirement for 24 hours of nursing coverage couldn't stand up to legitimate criticism. A requirement that those hours be filled by registered nurses, however, needed to address the issue of availability of those nurses. Nurse aide training was not objectionable, but nurse aide training off-site, with no guarantee that the student would return to the facility facilitating the training, was something else.

The basic issue, though, lay not in the substance of reform, but in the fact that the substance had to be imposed by Congress. Why didn't we learn from our colleagues in the hospital industry? Why didn't we establish our own accreditation standards? Why wasn't membership in our professional and trade associations a condition of meeting those standards? (And I personally assume much of the blame for the fact that it wasn't.) Say what you will about “deemed status” for hospitals—the idea that compliance with JCAHO standards is deemed to be in compliance with federal government standards—the hospitals at least have it. And they have it because their standards predated the advent of Medicare and Medicaid and the increasing role of government in American healthcare. (Are you listening, assisted living?)

So, it's not the standards that we should take issue with. If anything, the history of quality improvement in nursing homes gives us all much to be proud of. Forget the statement from the Congress's paid “analysts” (the Government Accountability Office [GAO] comes to mind) and certain unnamed chairpersons of the Senate's Special Committee on Aging. Forget recommendations from guild representatives (e.g., organized nursing), for whom a major goal seems to have been augmenting their own numbers, status, and reimbursement. I prefer to look at fact, not opinion. And it is fact that the use of both physical restraints as well as of psychoactive drugs has dropped precipitously since 1987. Data demonstrate the decreased incidence of pressure ulcers and catheterization. The literature is replete with evidence of more accurate assessments, increased and more effective hearing aid use, better toileting programs, and more advance directives.