Nursing Home Competition, Prices and Quality: A Scoping Review and Policy Lessons

Systemic failures in nursing home care-A scoping study

Nursing homes (also referred to as residential aged care facilities, or long-term care facilities) cater for older people on a respite or long-term basis for those who are no longer able to live independently at home. Globally the sector struggles to meet societal expectations since it is torn between three competing agendas-meeting the needs of residents, meeting the demands of regulators, and meeting the financial imperatives of nursing home proprietors. Competing demands indicate that the system lacks a clear understanding of its purpose-without a clearly understood purpose any system will become dysfunctional overall and across all its levels of organisation. This scoping study aims to summarise and synthesise what is already known about the systemic function and failures in the nursing home system, and the impact this has on the wider health and aged care system.

METHOD

MEDLINE, EMBASE, PSYCHINFO, CINAHL and SCOPUS were searched using the terms: (nursing home care OR residential aged care OR nursing home) AND (organisational failure OR institutional failure OR systemic failure), limited to English language articles, including all years up to the end of February 2021. In addition, we used snowballing of article references and Google searches of the grey literature. System-focused articles were defined as those that explored how an issue at one system level impacted other system levels, or how an issue impacted at least two different agents at the same system level.

RESULT

Thirty-eight articles addressed systemic issues as defined in four different contexts: United States (14), Canada (2), Australia (11) and European countries (11). Only four studies reported whole-of-system findings, whereas the remaining 34 more narrowly addressed systemic features of specific nursing home issues. The thematic analysis identified 29 key systemic issues across five system layers which consistently appear across every country/health system context. The negative outcomes of these systemic failings include: high rates of regulatory reprimands for unacceptable or unsafe practices; dissatisfaction in care experiences on the part of residents, families, and care staff-including a fear of being sent to a nursing home; and the perception amongst staff that nursing homes are not preferred places to work.

CONCLUSIONS

The key issues affecting nursing home residents, and the care home sector more generally, are systemic in nature arising from two key issues: first, the lack of shared agreement on the care home system's purpose; and second, the lack of clear governance and accountability frameworks for system regulation and performance at a national level. Addressing these two key issues must be the starting point for any 'real' nursing home system redesign that can achieve a seamlessly integrated system that delivers the outcomes nursing home residents and their families expect. 'Systems thinking' is required to simultaneously improve care quality and outcomes for residents, strengthen regulation and accountability, and enable financial viability.

Suffering while resigning to an unacceptable violation of dignity

BACKGROUND

The interaction of health personnel with relatives is linked to the quality of care results in nursing homes. However, there is limited knowledge of how relatives perceive being an integral part of the nursing home context. This secondary analysis has its starting point in an ethical concern about relatives' experiences in a previous study.

AIM

To critically discuss relatives' experiences of suffering when their next of kin live in a nursing home in a rural arctic context.

RESEARCH DESIGN, PARTICIPANTS AND CONTEXT

The critical hermeneutic stance is informed by Habermas. The secondary analysis is conducted on original data from five semi-structured focus groups with 18 relatives of residents of two nursing homes in a rural part of Norway. The theoretical framework concerning dignity, well-being, and suffering, as developed by Galvin and Todres, contrasts the analysis.

ETHICAL CONSIDERATIONS

The study followed the principles of the Helsinki Declaration. It was approved by the Norwegian Center for Research Data (NSD) (reg. no. 993360).

FINDINGS

The main theme of this study is: suffering while resigning to an unacceptable violation of dignity. This theme is deepened by two subthemes: (a) suffering while adapting to a relationship of dependence and (b) suffering while accepting the unacceptable.

CONCLUSIONS

Relatives experience suffering as a cross-pressure in their struggle to interact responsibly with health personnel in nursing homes. This may have a negative outcome, where relatives end up adapting to being silent witnesses to missed care and a violation of dignity.

Ownership, quality and prices of nursing homes in Australia: Why greater private sector participation did not improve performance

OBJECTIVE

This study examines whether greater private-sector participation in aged care can lead to better outcomes by comparing quality of care and prices of residential aged care facilities across three ownership types: government-owned, private not-for-profit and for- profit facilities. Australia, like many other countries, has been implementing market-oriented reforms aiming to promote greater consumer choice and increase the role of markets and private-sector participation in aged care.

METHODS

Using retrospective facility-level data, the study relates several measures of quality of care and a measure of price to ownership types while controlling for facility characteristics. The data covered six financial years (2013/14-2018/19) and contained 2,900 residential aged-care facilities, capturing almost all facilities in Australia. About 55% were private not-for-profit, 30% private for-profit and 15% government-owned.

RESULTS

Government-owned facilities provide higher quality of care in most quality measures and charge the lowest average price than private for-profit and not-for-profit facilities.

DISCUSSION

Reforms promoting private-sector participation in aged care are unlikely to result in effective competition to drive quality up or prices down unless sources of market failure are addressed. In Australia, the lack of public reporting of quality and the complex pricing structure are key issues that prevent market forces and consumer choice from working as intended.