Assessing Quality in Nursing Home

Introduction
Dementia is a serious and growing public health problem in the United States. As the prevalence of dementia increases with age, and as our population ages, an increasing number of people will be at risk for the various disorders which cause dementia. While there are more than 70 diseases that are thought to manifest in dementia, it is estimated that Alzheimer's Disease accounts for at least half of these cases, x The informal network of an individual suffering from dementia, usually the family, provides the majority of care in the early stages of disability. As the illness progresses, the behavior of a cognitively impaired person may include confusion, wandering, and outbursts of aggression. At some point, the stress and burden of providing care become overwhelming, and an alternative arrangement is sought by the caregiver(s). Often this alternative is institutionalization in a nursing home setting. 57% to as high as 78% of nursing home residents are estimated to have some type of dementia. 2 In recent years, there have been concerns and complaints by consumer/advocate groups regarding the quality and appropriateness of care provided for individuals with dementia in nursing homes. Many nursing homes have responded by segregating some of the residents suffering from dementia into Special Care Units (SCUs). The intent of SCUs is to optimize the quality of life for all residents in the facility: the cognitively intact as well as the cognitively impaired.
Addresscorrespondenceto MargaretM. Hastings,Ph.D., AssociateProfessor,UniversityofIllinoisat Chicago,2035 West TaylorStreet, Chicago, IL 60612. MargaretJ. Hampel,M.P.H., M.B.A., is with the Universityof Illinoisat Chicago.
Advantages of SCUs
Special care units have grown from the belief that nursing home residents with dementia require specialized care that has not been routinely available in nursing homes. Essentially, the rationale for SCUs has been to provide an environment which enhances individualized care and behavioral approaches to managing residents with difficult behaviors. Characteristics of these dementia SCUs include admission of residents with dementia; specially selected, trained and supervised staff; activities specifically designed for the cognitively impaired; family involvement; and a physical environment designed for the enjoyment, safety and segregation of residents with dementia.4~ Advantages as well as disadvantages of special care units have been identified.4,6-8 One of the benefits of special care units is the ability to recruit and train professionals and direct care staff for the special unit and to reduce staff turnover and bum-out. Families anticipate that better care will be provided for their demented relative due to the specialized nature and expertise of a special care unit. SCUs meet the emotional needs of family members often through family support groups, coaching on behavioral management techniques, and participation in plan of care meetings. Residents of SCUs benefit from a coherent and consistent program in an environment which is personalized, dignified, safe, and predictable. Resident social interaction and autonomy are encouraged. Behavioral problems are recognized as a response to cognitive deficits, not as "acting out," and are managed with programmatic and preventive interventions. Special care units also can be problematic. Some families resist special care units because they deny the severity of a family member's illness. Families may be concerned that SCUs actually will provide less competent care. Other families may be concerned about the additional expense that will be incurred through placement in a special care unit. Many believe that SCU placement assumes a relentless progression of deterioration. Others believe that segregation of residents with dementia may deprive these residents of the social and physical stimulation with cognitively intact residents. Staff may limit their expectations of residents, and recruitment of staff may be difficult because of their working only with severely disturbed residents. Another difficulty is establishing admission and discharge criteria for a special care unit because of the large percentage of nursing home residents who have some level of cognitive impairment and may not be assigned to the SCU. There are also accusations that some special care units are specialized in name only with little attempt to provide appropriate programs and services.2