Long-term care facilities, encompassing skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), and long-term acute care hospitals (LTACHs), play a vital role in providing ongoing medical and nursing care for individuals discharged from hospitals. These settings cater to patients requiring 24-hour post-acute rehabilitation and nursing care. Beyond these, assisted living facilities, residential care for the elderly, and adult care facilities also form part of this continuum, offering essential support with daily living activities and medication management, although they are not classified as healthcare facilities.
The patient demographic in long-term care is typically older, often presenting with multiple chronic illnesses and co-morbidities, making them more vulnerable than the general older adult population. Recent data indicates a shift in long-term care, with a decrease in residents within Medicare-certified SNFs – from 1.37 million in 2015 to 1.2 million in 2023. This decline is partly attributed to the tragic impact of the COVID-19 pandemic, which resulted in nearly 200,000 deaths in nursing homes. Simultaneously, staffing shortages exacerbated by pandemic-related staff deaths have further limited admissions. The growing preference for aging in place has also contributed to this trend, with older adults increasingly opting for in-home care or residential care alternatives to nursing homes. Despite the reduced admissions, healthcare utilization among long-term care residents remains high, with approximately half of Medicare SNF residents requiring hospitalization in their last year of life.
SNFs serve both long-term residents and post-acute patients discharged from hospitals. The proportion of post-acute patients, often medically complex and frail, has increased over the past decade, posing challenges to SNFs in maintaining consistently safe care environments. This evolving landscape has brought patient safety in long-term care settings to the forefront of healthcare priorities. Community-based residential care facilities, while not licensed for comprehensive nursing care, are increasingly seeking waivers to offer limited nursing services, further highlighting the shifting needs in long-term care.
Each type of long-term care facility is designed to meet specific patient needs with varying levels of services. Facilities providing medical and 24-hour nursing care, along with rehabilitation services, include:
- Long-Term Acute Care Hospitals (LTACHs): Specializing in the care of medically complex patients requiring extended hospital-level care, often for weeks or months. These patients typically suffer from chronic or critical illnesses, frequently recovering from ICU stays. LTACHs offer services comparable to acute care hospitals, including mechanical ventilation, complex wound management, and hemodialysis. Subject to the same stringent licensing and credentialing as traditional hospitals, LTACHs may be freestanding or integrated within acute care facilities. Patients in LTACHs require daily physician evaluation due to their complex medical needs.
- Inpatient Rehabilitation Facilities (IRFs): Focusing on intensive rehabilitation for patients recovering from surgery, trauma, or acute illnesses. IRFs aim to restore patients to their pre-illness functional status through at least 3 hours of daily physical or occupational therapy. A multidisciplinary team, led by a physician specializing in rehabilitation medicine, oversees patient care in these facilities.
- Skilled Nursing Facilities (SNFs): Catering to both short-stay post-acute patients expected to return home after a brief period and long-stay residents needing continuous 24-hour nursing care. While SNF patients generally do not require daily physician evaluations, they need specialized services such as intensive nursing, physical therapy, or wound care management.
Home and community-based long-term care services, which typically do not provide routine medical or nursing care, include:
- Assisted Living Facilities (ALFs): Offering supervised, independent living environments. ALFs provide core services like housekeeping, laundry, and meals within an apartment-style setting. Additional basic nursing care services, such as vital signs monitoring, medication assistance, and simple dressing changes, may be available for an extra charge. ALFs maintain 24-hour on-site staff but do not offer 24-hour nursing care.
- Residential Care Facilities for the Elderly (RCFEs): Providing housing and support for individuals needing assistance with most daily living activities, including bathing, dressing, and eating. RCFEs cater to residents who may have dementia or have experienced strokes but can still make basic decisions. Some RCFEs may have waivers to provide basic nursing assistant level services.
- Adult Care or Board and Care Homes: Typically housing adults aged 18-64 with developmental disabilities or conditions like paraplegia that hinder independent living. Similar to RCFEs, some adult care homes may also have waivers for basic nursing assistant level services.
Critical Safety Issues in Long-Term Care Settings
Preventable adverse events are alarmingly prevalent in long-term care. A 2014 Office of Inspector General (OIG) report revealed that 22% of Medicare beneficiaries in SNFs experienced adverse events such as delirium, falls, and pressure injuries during their stay, with half deemed preventable. Over half of these patients required subsequent hospitalization due to these events. Adverse drug events were identified as the most common type of adverse event in this and other studies within long-term care populations. A 2016 OIG report indicated an even higher incidence of adverse events in rehabilitation facilities, underscoring the pervasive nature of safety concerns across long-term care.
Subsequent OIG reports have consistently highlighted patient safety deficits and adverse events, including well-documented issues like medication errors, healthcare-associated infections, and the inappropriate use of antipsychotic medications. While patient complexity contributes to these events, the limited adoption of computerized provider order entry (CPOE) and other medication safety strategies in SNFs compared to hospitals is a significant factor. Falls among SNF patients are a particularly concerning issue, as detailed in a WebM&M commentary, which also provides evidence-based recommendations for prevention.
The Profound Impact of the COVID-19 Pandemic
The COVID-19 pandemic from 2019-2022 exposed severe vulnerabilities in nursing home infection control and prevention programs. AARP data indicates that as of mid-February 2024, over 2 million COVID-19 cases and nearly 200,000 deaths occurred among nursing home residents. Staff were also significantly affected, with 1.9 million cases, although, fortunately, fewer deaths. Despite federal safeguards like free vaccinations, mandatory trained infection preventionists in SNFs, AHRQ infection control training, and detailed guidelines, the winter of 2024 still witnessed a major surge in COVID-19 cases post-pandemic.
These ongoing infection control challenges underscore the difficulties in enhancing patient safety within nursing homes. Persistent issues such as chronic understaffing, inadequate training, low wages, and the absence of a robust patient safety culture continue to plague these facilities. Addressing these systemic issues is crucial for meaningful improvement.
Strategies for Enhancing Patient Safety in Long-Term Care: The Role of AHRQ Safety Program
Recognizing the urgent need for improvement, the Biden-Harris administration initiated measures in September 2023 to bolster patient safety in nursing homes. These included wage increases for direct care staff, mandating 24/7 registered nurse presence (previously only required during day shifts), enhancing overall staffing standards, and strengthening nursing home accountability. These recommendations stem from intensive scrutiny by CMS, AHRQ, OIG reports in 2021 and 2023, and the Coronavirus Commission on Safety and Quality in Nursing Homes, and are currently in various stages of implementation.
A foundational element in minimizing patient harm is establishing a strong culture of safety. However, safety culture in many long-term care facilities lags behind that of hospitals and ambulatory clinics. The AHRQ Surveys on Patient Safety Culture™ (SOPS®) Nursing Home Survey is a critical tool for assessing and monitoring safety culture in these settings. The most recent 2023 data reveals some progress in long-term care safety culture, but areas needing improvement persist, notably comfort in speaking up about safety concerns and ensuring adequate staffing levels.
AHRQ’s commitment to patient safety is exemplified through its comprehensive safety program for long-term care, which aims to provide resources, training, and tools to improve the quality and safety of care in these settings. While the original article does not explicitly detail a single, named “Ahrq Safety Program For Long Term Care,” it showcases numerous AHRQ initiatives and resources that collectively form a robust safety program. These initiatives, mentioned throughout the original article, represent AHRQ’s multifaceted approach to enhancing safety in long-term care.
Current Initiatives and Future Directions
Improving safety in long-term care necessitates ongoing research into patient safety issues, specialized education and training for healthcare providers in these settings, system-level interventions to enhance care coordination, and stronger incentives for long-term care facilities to prioritize patient safety. Recent federal attention has also focused on the impact of private equity firm ownership on nursing homes, which has been linked to poorer quality and safety outcomes.
The federal government is spearheading several initiatives to enhance safety and quality in long-term care. The CMS Care Compare website offers transparency by allowing patients and providers to compare long-term care facilities based on quality metrics, including patient safety measures like healthcare-associated infection rates, pressure injuries, and falls.
Furthermore, CMS has introduced minimum staffing standards for long-term care facilities participating in Medicare and Medicaid, directly emphasizing quality of care for residents.
AHRQ is actively funding research to understand the epidemiology of adverse events in long-term care and to develop effective prevention strategies. AHRQ has also created numerous resources to address safety in long-term care, including programs developed in response to the COVID-19 pandemic, such as infection control and prevention training programs for staff and the AHRQ ECHO National Nursing Home Action Network. These initiatives underscore AHRQ’s ongoing role in bolstering safety across long-term care spectrum.
The Joint Commission offers accreditation programs for nursing care centers, including SNFs and IRFs, emphasizing patient safety and hospital readmission prevention. The Joint Commission National Patient Safety Goals for nursing care centers, updated in 2024, mandate measures to prevent specific harms like falls, pressure ulcers, and infections, and to improve medication management. LTACHs and IRFs are accredited similarly to acute care hospitals and adhere to the same National Patient Safety Goals, also updated in 2024.
While these diverse efforts are crucial, addressing fundamental healthcare system issues like adequate staffing, fostering a stronger safety culture, and enhancing training remains paramount for sustainable safety improvements in long-term care. The COVID-19 pandemic illuminated persistent challenges in nursing home care, and ongoing studies continue to reveal long-standing issues, including inadequate safety cultures. CMS initiatives like the Patient Driven Payment Model (PDPM), designed to incentivize quality care through value-based payments, are being evaluated for their effectiveness in improving patient safety. The long-term impact of PDPM and other incentive models on patient safety in nursing homes is still under observation.
In conclusion, enhancing patient safety in long-term care requires a multi-faceted approach, with the AHRQ playing a pivotal role through its research, resources, and safety program initiatives. Addressing systemic challenges, fostering a culture of safety, and implementing evidence-based practices are essential steps toward ensuring the well-being of the vulnerable individuals in long-term care settings.
