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New nursing home paperwork is worth the effort

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.

March 06, 2011|Michael Hiltzik
  • Patty Pinero, an administrator at the 140-bed Woodruff Convalescent Center in Bellflower, looks over the federally mandated patient questionnaire, which can run 38 pages.
Patty Pinero, an administrator at the 140-bed Woodruff Convalescent Center… (Anne Cusack, Los Angeles…)

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.

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