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New nursing home paperwork is worth the effort

Original source:,0,788502.column

LA Times
Michael Hiltzik
March 6, 2011

The federal government's questionnaire can run 38 pages, but it gets nursing home residents involved in their own care, and that's a good thing.

We've all heard that government paperwork is a drag on productivity and a backdoor tax on the economy. Here's a case where it may actually be helping to improve people's lives.

The paperwork at issue is a questionnaire of up to 38 pages nursing homes now have to fill out for every resident upon admission. The form has to be filled out again periodically during the resident's stay, and again upon the resident's discharge, no matter whether he or she is being sent home to live with family, or sent to a hospital by ambulance in the middle of the night.

No question about it: This latest version of what's known as the Minimum Data Set, which has been required by the federal government since October, has added to the workload of overstressed and underpaid staff at the typical nursing home.

In addition to the resident's name, birth date and medical history, there are questions about whether the resident is feeling blue, knows what month it is, can remember sequences of words and can hear all right. There are three pages of questions about bedsores.

"The government likes statistics," says Patty Pinero, a top administrator at the 140-bed Woodruff Convalescent Center in Bellflower. "To me it's a mind-boggling process."

Some portions of the document can require several hours to fill out, in part because it requires nurses to interview residents at length. Pinero has had to give up some of her administrative tasks so she can spend time helping the nurses handle the load. She's hired a consultant to advise the center on filling out the questionnaire, and added a temp to enter the answers into a computer.

Nor is there any getting around it: Medicare and Medi-Cal use the questionnaire to set reimbursements to the center, and state regulators use it to check on the facility's quality of care.

Pinero's not alone. "It's a lot of paperwork," agrees Sharon Kearney, the consultant for Woodruff and other area homes, who points out that years ago, the forms required for data collected from incoming and departing residents were one page each. Facilities "have had to increase staffing because of the volume. It's time away from the residents."

Yet there's more to the change than that. It's part of a revolution in nursing care that has relegated the old picture of the nursing home - the last way station for your aged grandparents before the grave - to the dustbin. Today, gerontologists say, most residents stay six months or less before transferring back home or to facilities specializing in patients with the most severe mental or physical problems.

"It's absolutely no longer the case that the nursing home is the last home for the aged," says Robert A. Applebaum, an expert on long-term care at Miami University in Ohio. "For a lot of people, they're really being used for short-term care." One of the key questions on the new form, he observes, asks whether the resident expects to return to the community, and requires that the resident be asked directly.

"It used to be that it would be a nurse who would answer that question for the resident, and assume the answer," he told me. "The question about 'Do you want to get out' is really a big change."

Whether society is fully prepared to recognize that it's better to be cared for at home than in an institution is unclear. The difference puts more pressure on in-home housekeeping and medical services for the elderly. Unfortunately, that's one of the first services to be cut back by states facing fiscal pressure, including California.

The requirement that residents actively participate in their own care is part of an even bigger, and positive, change reflecting the evolution of nursing homes away from storage depots for the aged.

Ever since the federal government issued the first version of the nursing care data questionnaire in the 1990s, the patient was supposed to be part of the process.

"You were supposed to talk to them, talk to the families, talk to the staff, and review the medical records to answer the questions," says Debra Saliba, a geriatrician at UCLA and Rand Corp. who wrote the new version. "But that wasn't happening." Nursing homes would just transfer data from patient charts into the form. "The residents were completely excluded from the process."

Studies found that as a result, the data weren't reliable. "That was a problem because facilities were actually spending a lot of time on this," Saliba told me, "but it wasn't giving them anything useful."

Saliba's version tries to prevent such shortcuts by providing staff with specific, detailed questions to ask residents - "What month are we in right now?" "Have you had pain at any time in the last five days?" etc. But she says that when she interviewed nurses while developing the format, she was surprised to discover how little experience even the best staff members had in probing the patients' needs one-to-one.

"It was very revealing to me that they weren't doing the interviews because of the time pressures that are currently in nursing homes to get the meds passed and the vital signs checked, that the kind of fundamental assessment that needs to be done was getting short shrift."

Nurses didn't know how to perform the needed interviews and didn't know what to expect from their subjects. "They said: 'We can't ask questions of residents.... What will I do if they cry? What if they think these questions are too personal?' "

With those issues in mind, the federal Centers for Medicare and Medicaid Services prepared extensive training materials including videos demonstrating patient-interviewing techniques for sections in the questionnaire such as mood, cognition, pain, preferences. Saliba took a team to 91 nursing homes to test the questionnaire and get feedback from staff.

Some experts say the government questionnaire may still need some refinements. Turnover among nursing home residents is so much greater now than it was when the first questionnaire was developed more than a decade ago that regulators may not fully understand the burdens of filling it out.

"The volume of paperwork for people coming in and going out has really become dramatic for these facilities," says Applebaum, who has been tracking the evolution of the government requirement. "When you've got a system with that much turnover, you have a problem."

Saliba notes that the length of the form is a bit deceptive; not all sections have to be completed in all cases. Moreover, nursing homes are already learning to manage the burden better. Pinero says that parts of the interview that used to take her staff three hours are now done in 90 minutes, and she hopes to cut that to a half-hour within a few months.

And some of the blame belongs not to the government, but to the new world of nursing care. "People don't like change generally, and this was a huge change in long-term care," says Kearney. "But any time you have to involve the resident in the process, that's always better."