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Strive-Achievement Quality of Care
Standards:
Many mentally ill elders have traded the formal mental health system for custodial care in a nursing home. According to Ferrini and Ferrini, “Despite the variety of mental health services available, older persons are underserved.”[1] This population’s care routings are often the result of biases that professionals have towards treating elders. Some health care providers may believe treating older individuals is not worthwhile because elders only have a few years left to live. Health care providers also “tend to attribute many symptoms of distress to organic symptoms or old age…. Other biases maybe due to lack of knowledge about the characteristics, needs, and concerns of older people and special considerations in dealing with an older patient.”[1] Working with elders, particularly the sick or very old, may force practitioners to confront the difficult personal questions of their own aging, decline, and eventual death. A limited supply of health care professionals skilled in both geriatrics and mental health care creates a barrier to oral health care service delivery to these populations. Another concern is the lack of cooperation and coordination among private health care providers, community agencies and chronic care institutions, which often results in waste and duplication of services. An interdisciplinary approach to treating the health care of elders holistically is needed to assure shared responsibility and cooperation among practitioners. Collaboration can help eliminate professional biases, address resource shortages and improve the coordination of care for this underserved population. The oral health of geriatric patients is vital to their overall health and well-being. It is important to ensure that oral health care is not neglected in the face of personnel and service delivery shortages, professional bias and limited resources. Guarantees must be made through professional certification and licensure requirements for facilities entrusted with the care of the elderly and mentally ill. Establishing Standards of Oral Health Care An effective way to improve the oral health of individuals in long-term and chronic-care facilities could be to introduce a quality of care standard designed specifically to encourage institutions to assume responsibility for the provision of quality oral health care. This standard would require all care facilities to have written policy requiring specific oral health care procedures and to ensure that it is followed. These procedures should include routine daily hygiene, routine periodic prophylaxes and oral cancer screenings. The quality of care standard should include measurable outcomes so that the standard of care actually provided can be compared with the quality expected. The standard should also include a periodic quality check to verify and document that the oral hygiene process is in fact practiced routinely in the facilities by skilled health care professionals. A documented quality improvement process should be in place to monitor the oral health of the elderly and mentally ill residents who cannot care for themselves. Such a process would evidence that oral hygiene is routinely practiced and that standards of oral care are met. Implementing quality practices for dental hygiene will provide assurance appropriate oral health care is given. Resident care plans and annual evaluations could be conducted using screening tools to monitor oral conditions through periodic dental examinations of randomly selected residents. Approaches for Achieving a National Standard An effective way to improve the oral health of individuals in long-term and chronic-care facilities is to mandate standards for oral health care. Standards of care are set by regulatory and licensing organizations. Currently, nursing homes are primarily regulated by three entities: the Joint Commission for the Accreditation of Health Care Organizations (JCAHO), state departments for professional licensing, and certification as a provider by Medicare and Medicaid services.[2] Requiring all long-term care facilities and chronic-care facilities to meet a strict quality standard of oral health care would assure dental hygiene for the most dependent segment of the elderly and mentally ill populations. JCAHO accreditation is a voluntary process and may be costly. It is a painstaking process of assuring that specific policies and processes are actively in place. Accreditation requires special staff capable of interpreting regulatory standards, assessing operations and managing resources to affect their practice. Most hospitals are JCAHO accredited, but because of limited resources, JCAHO accreditation is often not an option for nursing homes.[2] consequently, standards of care vary among nursing homes. In contrast to accreditation, Medicare and Medicaid certification programs are of value to nursing homes because over 60% of their revenue is generated from participation in these programs. Most nursing homes elect Medicare and Medicaid certifications over JCAHO accreditation because, without certification, they would not be able to care for residents enrolled in these programs.[3] State departments for professional licensing are very effective in imposing compliance with quality of care standards in nursing homes. Since all nursing homes are required to abide by state laws that regulate health care, nursing homes must comply or to close.[2] The biggest drawback in implementing standards of care through state licensing departments is that each department operates independently. Thus, every state determines and enforces its own laws, rules and standards of care, meaning that standards differ from state to state. Petitioning for standards of oral health care to be incorporated into licensing requirements would involve lobbying for legislative change in each state, resulting in 50 possible variations and interpretations of the originally intended standard of care. Conclusion Requiring facilities to measure up to higher standards for oral health care should result in increased expectations of the facility’s caregivers, improved caregiver performance and elevated commitment to providing quality oral health care. The American Dental Association (ADA) can petition the state and national accrediting organizations (i.e., JCAHO, Medicaid, Medicare) to add oral health quality of care standards to credentialing requirements for long-term care facilities. Requiring all long-term care facilities and chronic-care facilities to meet a strict standard would assure quality oral health care for the most dependent segment of the elderly and mentally ill populations. Medicare and Medicaid certifications could provide the most effective forum for implementation of a quality of care standard. These programs are not only nationally funded and regulated, but also are major sources of revenue for nearly all participating facilities. The reliance of nursing homes on funding at the national level through Medicaid and Medicare creates a commitment to abide by specific standards, into which oral health care should be incorporated. The Special Care Dentistry Association and American Dental Hygienists’ Association, along with ADA, should support initiatives that will motivate the Medicare and Medicaid programs to include standards and regulations supportive of quality oral health care, especially for geriatric and mentally ill residents in long-term care facilities. These three professional groups together have the ammunition to improve the delivery of oral health care services by using their influence to raise public awareness regarding the high correlation between good oral hygiene and individual overall health. Efforts need to be made to motivate the government to adopt and require standards of oral health for Medicaid and Medicare certification. A strategy could be developed that models the pay-for-performance incentives for physicians currently proposed by the Centers for Medicare and Medicaid Services. A similar incentives program could be developed and applied to oral healthcare practitioners. Such a program would motivate quality oral health care practice and set the bar for a minimum standard of care expectation. As members of the dental professions, we should expect no less than a minimum quality of care standard for this underserved population. References 1. Ferrini AF, Ferrini RL. Health in the later years.
3rd ed. New York: McGraw-Hill; 2000: 320-8. Amanda Murray-Nash is a junior dental hygiene student at Southern Illinois University (SIU) in Carbondale, Illinois. She is active as a student member of ADHA at SIU and has served as class historian for the last two years.
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By
Amanda Murray-Nash
