Long-Term Care in Transition: The Regulation of Nursing Homes

Invaluable reading for health care professionals involved in the management of nursing homes, it includes lessons learned from the regulatory experience for the health sector as a whole.

Category: Healthcare

This title is part of the Healthcare Administration list.

Of Interest:

Competitive Strategy for Health Care Organization

Dynamics of Institutional Change: The Hospital in Transition

Harvest Moon: Portrait of a Nursing Home

Hospitals, Health and People

Management of Hospitals and Health Services: Strategic Issues and Performance

The White Labyrinth: Guide to the Health Care System

Long-Term Care in Transition is a carefully documented case study of the changes that took place in the regulation of nursing homes in New York between 1975 and 1980. It covers the history of the regulatory offensive in New York and strategies of control and their effectiveness, touching on such subjects as professional standards, rate-setting, reimbursement, criminal prosecution and consumers. Invaluable reading for health care professionals involved in the management of nursing homes, it concludes with some of the lessons learned from this experience for the health sector as a whole. While regulations have changed since 1980, David B. Smith has written a new preface, which puts the study in perspective.

David Smith's "Preface" to this new edition of his 1981 book is more than the typical perfunctory words on why the topic is still relevant. Smith's "Preface" goes for more than three pages of close type and has endnotes. In it, he gives an analytical overview of areas of progress and failures in the nursing-home industry. But as he notes, even the progress has not changed the field so that it is no longer plagued by the troubles of some two decades ago. Furthermore, legislation such as New York State's Balanced Budget Act of 1997 have brought new pressures to bear on nursing homes. Many nursing homes are operating under Chapter 11 bankruptcy protection in an effort to remain barely solvent. Though there have been shifting conditions within the field over the past couple of decades, nothing has changed so that the nursing-home field has changed substantially or is on the road to effectively dealing with its troubles by now well-documented in works such as Smith's "Long-Term Care in Transition."

Smith was originally motivated to write it with the help of a foundation grant in the hope that the troubles and even scandals coming to light when nursing homes were a relatively new phenomena could be remedied before they set into the field. But the problems were not untangled at the time when political and public awareness and concern were directed to them. With the federal and state budget problems of recent years, changes in views toward welfare, and the problems in the broader health-care system which are drawing attention, the chances of dealing with the problems of nursing homes has become more remote. As nursing-home operators, the elderly, and their relatives were "muddling through" the circumstances under stress and uncertainties in 1981 when the book was first published, so are they continuing to muddle through today. Smith's work gives them a goal of efficient, respectable, and effective nursing-home operations, standards, and care to work toward despite the problems, including in some cases abhorrent conditions and callous care.

"Long-Term Care in Transition" focuses on the nursing-home field in New York State. New York's nursing-home system was the focus not only because the state was a large populous state with a wide diversity of residents, but also because "[i]n New York, industry abuses and the excesses of the regulatory reactions to them reached extremes unequaled at any other time or place." Abuses in New York's nursing homes, some of them horror stories, had received national attention. Also, as a state with a liberal, progressive, image, New York was regarded as one particularly interested in resolving both humanitarian and administrative problems with nursing homes. Identification of the problems in the New York State nursing home system, legislation regarding the system, and cooperation among politicians, nursing-home owners, and the public would lead the way to improvements in nursing homes throughout the country.

Smith studies different kinds of material to get an accurate picture of the operations, financing, staffing, residents, owners, and government officials and agencies regarding nursing homes in order to arrive at relevant and practicable recommendations for them. Investigative news articles are found with statistics from studies from public and private organizations. Experiences and ideas from nursing home owners are found with legislative and regulatory activities of governments officials. Stories from nursing-home employees and residents are found with laws applying to nursing homes and criminal prosecutions of some nursing home owners or employees.
After presenting and assessing this great quantity and variety of material, Smith puts forward four key proposals which would go a long way toward greatly reducing the problems common among nursing homes. If put into effect, Smith's proposals would prevent such problems from returning in the future, so that nursing homes could attend mainly to their aim of providing satisfactory care for the infirm elderly.

Smith's four proposals are decentralization, miniaturization, desegregation, and reappropriation. Certain ones sound so obvious and reasonable to different readers that these are not the rule in nursing homes attests to just how contorted and inappropriate the situation with nursing homes can be. The end of the author's four key proposals is to revise this typical situation so that nursing homes are no longer owned primarily by opportunistic businesspersons aiming mainly to partake of government finances available for this social service. Such businesspersons were often virtually absentee owners; which predictably resulted in the poor management and ill-trained staff behind the widespread negligence and occasional abuses. Smith wants to place responsibility for the operation and policies of nursing homes with those who are most affected by these.

"Miniaturization" refers to seeing nursing homes as small units which may not resemble institutions at all. This proposal is buttressed by studies indicating that nursing homes have not benefited either financially or in terms of service by economies of scale that have proved desirable in other business, including hospitals and other health services. "Desegregation" refers to providing nursing home services in the "least restrictive, least segregated environment that is feasible." The different needs, as well as the relative degree of health, of elderly persons should be recognized so that they are not automatically consigned to nursing homes and thereby removed from the mainstream of society. This not only is corrosive of social unity, but also works against understanding health problems of the elderly so they can be dealt with effectively for the good of society.

With the aging of the population, demands for improved nursing homes are sure to intensify. In "Long-Term Care in Transition," Smith forwards a reasoned critique and related germane prescriptions which satisfy the considerations of financial solvency, suitable health care, and observance of the social values of humaneness and equality.

David B. Smith is a professor of Healthcare Management at Temple University. His studies in the field of health care have attracted funding and awards from foundations.

Professor Smith received his Ph.D. at the University of Michigan in Medical Care Organization and has previously held faculty positions at the Graduate School of Management at Cornell University and the Department of Community Medicine at the University of Rochester. He has also served as an IPA Fellow in the Office of Research and Policy of the Health Care Financing Administration. Currently, he is a Professor and Chairman of the Department of Health Services Administration in the School of Business and Management at Temple University.

He received a 1995 Robert Wood Johnson Health Policy Research Investigator Award for research on the history and legacy of the racial segregation of health care. He is the author or co-author of four books on the organization of health services and numerous articles in peer reviewed journals.