OBRA: One thing the feds got right

Study shows 1987 law has led to improved nursing home care

In 1987, the Omnibus Reconciliation Act (OBRA) called for a dramatic overhaul of the nursing home quality assurance system, following published reports about resident abuse, neglect and a lack of regulation and oversight.

In retrospect, it looks like the feds made the right call.

An analysis published in the February 2020 Journal of Post-Acute and Long-Term Care Medicine indicates that between 1985 and 2015, the quality of nursing home care improved, even as physical and cognitive function among residents decreased. Findings from the study, by researchers at Brown University and the U.S. Department of Veterans Affairs Medical Center in Providence, Rhode Island, include the following:

Facility characteristics

  • The nursing home industry decreased in size, from 19,068 facilities in 1985 to 15,686 in 2016.
  • There has also been an increase in the percentage of facilities that are nonprofit (25% in 1985 and 31% in 2015) and that are dually certified by both Medicare and Medicaid (33% in 1985 and up to 97% in 2015).
  • Between 1995 and 2015, chain membership increased from 51% to 57%, the percentage of facilities with an Alzheimer’s special care unit increased from 11% to 15%, and overall nursing home occupancy rates declined from 87% to 81%.

Resident composition

  • Data suggest that although the average age of residents remained constant, the percentage of those who were racial and ethnic minorities increased from 7.8% in 1985 to 20.7% in 2015.
  • The average percentage of females decreased from 72% of residents in 1985 to 67% in 2015.
  • The prevalence of long-stay residents within nursing homes remained stable at 69% of all residents between 1985 and 2015.
  • The percentage of residents admitted from the hospital increased from 67% in 2000 to 85% in 2015.
  • There has also been a shift of payer types over time. Between 1992 and 2015, the average percentage of residents with Medicaid as a primary payer decreased from 64% to 58%, whereas the average percentage of residents with Medicare as the primary payer rose from 9% to 15%.
  • Resident physical and cognitive function decreased over the years. The average ADL (activities of daily living) dependency score among nursing home residents increased slightly, from 15 to 17, between 2000 and 2015.
  • Residents who required assistance in bathing increased from a national average of 89% in 1985 to an average facility average of 96% in 2015.
  • Assistance with dressing rose from 74% to 92%, assistance with transferring from 60% to 85%, assistance with toileting from 49% to 88%, and assisting with eating from 38% to 56%.
  • There was a decrease in the percentage of residents who were bed-bound, from 6% in 1985 to 4% in 2015, but an increase in the percentage of those who were chair-bound, from 39% to 64%.
  • The percentage of residents with dementia increased from an average of 39% in 1995 to an average of 45% across the facilities in 2015.

Quality of care

Overall, quality process and outcome measures have improved since the passage of OBRA 1987, according to the researchers:

  • Average direct care staffing hours have increased over time, with the greatest increases observed among certified nursing assistants.
  • The average proportion of residents being physically restrained decreased dramatically from 19% to 1%, and the percentage of residents receiving antipsychotic medications inappropriately, as a chemical restraint, decreased from 16% in 2000 to 12% in 2015 (although there was a peak of 22% in 2005).
  • There was not much change in the proportion of facilities cited for medication errors over this time period.
  • The proportion of residents with pressure ulcers decreased from 8% to 6%.
  • Congruent with an increased need for assistance, bowel and bladder incontinence increased from 42% to 44%, and 49% to 62%, respectively.

In addition to helping bring about quality-of-care improvements, OBRA 1987 was also successful in implementing and enforcing the MDS (Minimum Data Set) resident assessment survey, which is required for all residents in Medicare or Medicaid certified nursing homes, the researchers report.

“Because of the aging-in-place movement, we are seeing lower occupancy rates in nursing homes,” they write. “Older adults without financial resources – disproportionality, minority older adults – are becoming an increasing proportion of nursing home residents, as they may not be able to as readily access these care alternatives.

“Current and future policies should focus on expanding equitable access to the remaining long-term care services and supports in the continuum of care, particularly given the policies and initiatives focused on decreasing nursing home utilization through support of home and community-based alternatives.”

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