THE OBRA-87 NURSING-HOME REGULATIONS AND IMPLEMENTATION OF THE RESIDENT ASSESSMENT INSTRUMENT - EFFECTS ON PROCESS QUALITY

OBJECTIVE: To characterize changes in key aspects of process quality r eceived by nursing home residents before and after the implementation of the national nursing home Resident Assessment Instrument (RAI) and other aspects of the Omnibus Budget Reconciliation Act (OBRA) nursing home reforms. DESIGN: A quasi-experimental study using a complex, mult istage probability-based sample design, with data collected before (19 90) and after (1993) implementation of the RAI and other OBRA provisio ns. SETTING AND PARTICIPANTS: Two independent cohorts (n > 2000) of re sidents in a random sample of 254 nursing facilities located in metrop olitan statistical areas in 10 states. INTERVENTION: OBRA-87 enhanced the regulation of nursing homes and included new requirements on quali ty of care, resident assessment, care planning, and the use of neurole ptic drugs and physical restraints. One of the key provisions, used to help implement the OBRA requirements in daily nursing home practice, was the mandatory use of a standardized, comprehensive system, known a s the RAI, to assist in assessment and care planning. OBRA provisions went into effect in federal law on October 1, 1990, although delays is suing the regulations led to actual implementation of the RAI during t he Spring of 1991. MEASUREMENTS AND ANALYSES: Research nurses spent an average of 4 days per facility in each data collection round, assessi ng a sample of residents, collecting data through interviews with and observations of residents, interviews with multiple shifts of direct s taff caregivers for the sampled residents, and review of medical recor ds, including physician's orders, treatment and care plans, nursing pr ogress notes, and medication records. The RNs collected data on the ch aracteristics of the sampled residents, on the care they received, and on facility practices. The effect of being a member of the 1990 pre-O BRA or the 1993 post-OBRA cohort was assessed on the accuracy of infor mation in the residents' medical records, the comprehensiveness of car e plans, and on other key aspects of process quality while controlling for any changes in resident case-mix. The data were analyzed using co ntingency tables and logistic regression and a special statistical sof tware (SUDAAN) to assure proper variance estimation. RESULTS: Overall, the process of care in nursing homes improved in several important ar eas. The accuracy of information in residents' medical records increas ed substantially, as did the comprehensiveness of care plans. In addit ion, several problematic care practices declined during this period, i ncluding use of physical restraints (37.4 to 28.1% (P < .001)) and ind welling urinary catheters (9.8 to 7% (P < .001)). There were also incr eases in good care practices, such as the presence of advanced directi ves, participation in activities, and use of toileting programs for re sidents with bowel incontinence. These results were sustained after co ntrolling for differences in the resident characteristics between 1990 and 1993. Other practices, such as use of antipsychotic drugs, behavi or management programs, preventive skin care, and provision of therapi es were unaffected, or the differences were not statistically signific ant, after adjusting for changes in resident case-mix. CONCLUSION: The OBRA reforms and introduction of the RAI constituted an unprecedented implementation of comprehensive geriatric assessment in Medicare- and Medicaid-certified nursing homes. The evaluation of the effects of th ese interventions demonstrates significant improvements in the quality of care provided to residents. At the same time, these findings sugge st that more needs to be done to improve process quality. The results suggest the RAI is one tool that facility staff, therapists, pharmacy consultants, and physicians can use to support their continuing effort s to provide high quality of care and life to the nation's 1.7 million nursing home residents.