Since the Nursing Home Reform Act of 1987, public policy makers, consumers and providers have expressed growing interest in the quality of long-term care in nursing homes and other long-term care settings. The Nursing Home Reform Act, known as “OBRA 87,” transformed federal oversight of nursing home quality from its traditional emphasis on structure and process indicators to a focus on maintaining and improving resident outcomes. Since the passage of that landmark federal legislation, consumers, providers, regulators, insurers, and researchers have continuously struggled with how to define measure, assess and ensure long-term care quality.
The purpose of this paper is to introduce a largely overlooked feature of the long-term care system -- direct-care workers -- into the long term care quality debate. For the typical nursing home resident, direct-care staff -- not nurses or doctors -- provide eight out of every ten hours of the care they receive (McDonald, 1994). For home care clients, every hour of non-skilled nursing service is provided by paraprofessional workers. Our thesis is that the quality of long-term care -- the recipients’ clinical and functional outcomes and quality of life -- is significantly influenced by the attributes these workers bring to their caregiving jobs, the education and training they receive, and the quality of their jobs. The attitudes, values, skills and knowledge of these workers, how they are compensated and rewarded, and the way their jobs are organized and managed, all have a role to play in determining long-term care quality. Workforce development activities designed to increase the capacity of these individuals to participate effectively in long-term care settings should be integrated into all ongoing and new long-term care quality improvement and quality assurance initiatives.
The paper addresses the following topics:
- The scope of federal quality initiatives to date;
- Why workforce development should be considered an important dimension of long-term care quality;
- The key policy and practice constraints that impede linking workforce development issues and long-term care quality;
- Examples of quality improvement initiatives that have incorporated workforce development activities; and,
- Applied research activities to examine the link between workforce development and long-term care quality.