The Quality of Care in Long Term Care Facilities


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With improvement in the quality of care and the growth in the aged population, the demand for long-term care is on the increase. The trend is accompanied by the need for protection of the rights of these aged citizens to welfare, safety, and health. The institutionalized elderly in long-term care facilities are in need for concerted care and support as some are not in a position to cater for their needs and daily living (Brownie & Nancarrow, 2013). There is a multiplicity of factors which have converged in such a manner that considerable attention has emerged in relation to quality of life and quality of care in the healthcare settings.

Within the health care sector, the elderly are the most consumers of health care services. The problem becomes worse in the event that the safety and health needs of the individuals are not adequately addressed in their immediate settings. Hence, it is beneficial for the individuals and the health care sector that the elderly are living in a safe and healthy environment and that their quality of life is assured. Research on the factors affecting the quality of life for the residents of the long-term care facilities is critical towards improving their health and cutting the cost for the health care system.

For the purpose of the current study, the focus is on the identification of these factors towards the end of addressing any shortcomings and improving the quality of care for the residents. Hence, the scope of the study is the factors, circumstances, and policies relating to care of the elderly in long-term care facilities. The outcome of the study will inform policies and decisions geared towards improving care and quality of life.

Literature Review

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Long term care is critical for the elderly because of the role it plays in their quality of life in the period leading to their final days. According to Ouslander et al. (2014), old age comes with major challenges for the individuals. In most cases, the elderly experience declined functioning, which affect their potential for personal care. By and large, the elderly are most dependent on other people for the necessary support and assistance to live a quality life. Long term programs and policies in the United States have been faced with major challenges; key among them the deficiency of quality in the care provided to the residents (Backhaus et al., 2014). The programs and policies are balanced towards the nursing home model, which despite having a practical quality, have been linked to deficiency regarding providing quality of care. Research into the use of this model has continued to point out the deficiencies in terms of the quality of care, indicating the need for improvement and seeking of alternative models for long-term care.

Staffing and the Quality of Care

The quality of care for the residents in nursing homes and other long-term care facilities is extremely dependent on the adequacy of the providers of the care (Ball et al., 2013). Recent studies have revealed that there are more than three million certified nursing assistants as well as licensed nurses working in the facilities (Ouslander et al., 2014). The population is increasingly aging, which means that the demand for the nurses within the facilities will continue to increase. In the coming decade, the demand will increase up to five million, which means that the current number of nurses will be inadequate to cater for the needs of the residents. Another study by Backhaus et al. (2014) indicated that even the current number of nurses is inadequate to cater for the current demands, despite the criticality of their services in the quality of care. With the increase in the rate of nurse turnover, a grimmer picture is painted for the recipients of care within the nursing homes and other long-term care facilities.

The inadequacy of nursing and other staff within the long term care facilities is revealed as a function of limitation in the quality of care to the residents. A study carried out by Ball et al. (2013) indicated that the delivery of quality care has a positive relationship with adequate nurse staffing. Overall, the study revealed that nursing is an important factor in positive patient outcome. Staffing remains a critical issue in health policy creating a huge consensus among policy makers on the importance of addressing the issue. A research by Ouslander et al. (2014) showed that nursing is a major element of health care delivery and the adequacy of nurses has a major impact on quality and safety of care. Regardless of the consensus on the role of nurse staffing in the quality and safety of care, there is still a lack of research agreement on the nature of the policy that is better placed to address the staffing problem. Hence, more research is critical to establish the necessary policy steps to address the staffing issue for quality care.

Patient Identifiers in the Quality of Care

There is still a limitation in research on the patient characteristics that have an impact on the quality of care for the elderly within the long-term care facilities. However, there is evidence that patient information plays out in the identification of the targets for care improvement within the settings. Reporting of the intra or inter-provider, information is indicated with critical information on the nature of patients being served within the care settings. Research has focused on the provision of care to different segments of patients and the diversity that arises from the fact that the recipients of care are not the same across the board (Pines et al., 2013). Public reporting has been shown as a stimulant for improvement as a function of identification of the needs of the different populations based on their unique characteristics (Nelson et al., 2015). The idea is that the nursing staff is able to target the services they provide to the patients following adequate identification of the unique characteristics that the patients present.

Whether recognition of the patient demographics will play a role in improving the quality of care is a question that has been faced with controversy in research. On the one hand, it is possible that bias and prejudice can impact the quality of care where the patient demographics are made obvious. On the other hand, it is possible that customized care to the recipients is possible where the demographics of the patients are known (Pines et al. 2013). Research is not adequate to address the controversy, indicating the criticality of such studies that will indicate the exact role played by the patient identifiers in their care. Research is necessary to establish the role of such practice as use of armbands with patient demographics in improving the quality of care for the patients within the long-term care settings. Where such measures are proven effective, they can be implemented in practice.

Government Regulations and Reimbursements in the Quality of Care

In long-term care, quality assurance initiatives have focused on the role played by the government towards the end of ensuring quality of care. The focus on regulatory programs has led to research evidence on the role that the government can play in improving the safety and quality of care within the settings (Singh, 2014). Among the areas of focus has been the role of certification of the providers of care in long-term care facilities such as the nursing homes. The government, through legislation, regulation, and judicial policies, has worked towards creating the fundamental standards for quality of care. In fact, the use of publicly-funded services is the basis for making the long-term care facilities well suited to providing safe and quality care. The U.S. Department of Health and Human Services (DHHS)’s Health Care Financing Administration (HCFA) is the basis for the administration of the publicly-funded such as Medicare and Medicaid programs. The requirements of the programs are the basis for ensuring the standard level of quality.

While there is adequate research on the role of government regulations on the quality of care, there is limited research on the role played by reimbursement in the promotion or inhibition of the quality of care in long-term care settings. According to Folland, Goodman, and Stano (2016), the limitation is due to the scantiness of conclusive information on the subject. There are studies that have associated inadequacy of quality of care to diminutive Medicaid payment rates (Singh, 2014). However, there are studies that have attributed the low quality of care to the increase in the demand for the services, making it hard for the programs to cater for the demand. While there is still little known regarding the impact of reimbursement on the services offered within the institutional settings, there is even less information about the effect on care in other settings, including home and community-based programs. Evidently, there is a need for more research on the impact of reimbursement and other government programs in improving the quality of care for the elderly.

Technology in Service Provision

The long-term care industry has been facing serious challenges in addressing the acuity of the residents. These are individuals in need for daily support and assistance to have the necessary quality of life. Regardless of the shortage of the nurses in the country, there is still need to provide the necessary care to the residents. The shortage indicates a deficiency in the necessary assistance for the residents, which has been proposed to be addressed through increased use of technology. Novel approaches to service delivery are proposed as the means for dealing with the challenges. Researchers, government policy makers, service providers, and manufacturers have pointed out the role of technology-based solutions to the pressures placed on the institutions. Technology is supposed to have the potential for relieving the pressure, revolutionizing care, and improving the quality of care and life for the elderly within the long-term care institutions. Aging technology could hold the potential for better service provision in the settings.

However, implementation of technology is facing serious limitations within the settings. Research has indicated that the level of implementation of the technology has remained minimal (Carretero et al., 2012). While use of technologies such as telehealth services could make a huge difference in the quality of care and quality of life, their adoption is not at the level that is should be to provide the necessary benefits. Some of the challenges explaining the low level of adoption of technology include inadequacy of information on the existence of the technologies, apparent lack of financial resources, failure of regulatory processes, and lack of standards for technology within the industry (Mei et al., 2013). The findings from the research indicate a need to address the challenges for better adoption of technology, especially because of the shortage of the nursing staff amid increase in demand for the services. Hence, more research is critical for identification of policy solutions to the challenges as use of technology in long-term care settings is a matter of urgency.

The Role of Telehealth Services

Telehealth or telemedicine platforms have been shown in recent research to provide the necessary connection between long term care and health care services (Kvedar, Coye, & Everett, 2014). They are tools for timely access to health care for the aged. Car, Huckvale, and Hermens (2012) added that telehealth is providing the health care services that are critical for quality of life within the facilities for providing the needs of the elders. All that is required is to set aside a room from where the health care services can be provided to the residents of the long term care facilities or the alternative long term care models for the elders. Drugs are not the only services that can be provided using the telehealth model. With the development in the technology, it is no longer necessary to always visit the health care facility to get care.

For the convenience, efficiency and responsiveness of the services are being brought closer to the elders. Diagnosis of diseases within the long term care facilities and even the alternative care arrangements are being made to bring the services to the people who are in need rather than taking the people to the services (Ventola, 2014). Long term care facilities are increasingly setting aside a room or kiosk with secure, private audio-visual connections which can be used for the purpose of performing diagnostic services critical within the settings. Diagnostic imaging is increasingly becoming an important part of the care continuum. Conventionally, the patient would need to visit the health care services to access the services. However, the recent past has witnessed development in mobile tools that can be brought to the facility to provide the services to the residents.

Modern technology has allowed for safe movement and use of the mobile X-ray and Ultrasound imaging for use in settings away from the health care organization. The tools are mobile, which allows for their movement from one setting to another. Fast response and speedy diagnosis are possible where the tools are easily moved from one place to another. For the residents of long-term care, it becomes more convenient to bring the services to where they are (Car, Huckvale, & Hermens, 2012). Most of these individuals are aged and the aging process has weakened their bodies. Hence, regular movement to the health care facility can create more damage to their bodies. Investing in telehealth, hence, provides the necessary convenience and cutting down the cost of care for the elderly.

Despite the benefits offered by telehealth technology, any implementation of technology is normally a complicated affair. The cost associated with the implementation of the technology is another barrier to the use of the technology. The challenges are made worse by the reality that there is no clear guideline at the policy level for the reimbursement for telehealth. While the government could play an important role in the adoption of the technology, the lack of guidelines has hindered adoption and use of the technology. Generally, the adoption of telehealth, especially the costly diagnostic equipments is being hindered by the high cost of adoption and maintenance (Kvedar, Coye, & Everett, 2014). There are other challenges including inadequate adaptability to the long term care settings and resistance to change among other challenges. The challenges have to be addressed for the benefits of telehealth to be achieved.

Alternative that can Improve the Quality of Long-Term Care

Improving the quality of care for the elderly citizens should be the focus of long-term care. Evidence from research indicates an increase in the demand for long-term care services from the institutions such as the nursing homes. The demand is expected to grow further in the coming decade because of the increase in the aged population. With the high demand and the shortage of nursing staff, the quality of care is further negatively impacted (Brownie & Nancarrow, 2013). According to Reuben and Tinetti (2012), it is time for the consumers of the aged care services and their families to seek alternative sources of care to relieve the pressures from the long-term care facilities. As much as possible, research evidence has provided the benefits of using home-based care as an alternative to long-term care facilities such as the nursing homes. With proper arrangements for the health care needs, providing care for the elderly from the comfort of their homes will not only relieve the pressure from the long-term care facilities, but also improve the quality of life of the patients.

There are other alternatives to long-term care facilities that do not involve the unnecessary confinement of the residents. Reuben and Tinetti (2012) investigated the role being played by respite care in improving the quality of care and the quality of life for the elderly citizens. With this arrangement, the individual has a short-term residence in a community for the seniors. Given that the settings take the form of assisted living or support for individuals with other forms of disabilities such as loss in memory, the kind of care provided is suited to the needs of the patient. The provision of day-to-day supportive services amid an environment of social engagement and stimulation is critical for the promotion of the quality of life of the patient (Burack et al. 2012). In the environment where the demand for long-term care is increasing, policy makers and health care practitioners should seek alternatives that will allow the aged to access the kind of care necessary to have a comfortable life. Thus, more research is critical to establish the model of the alternatives that will provide the necessary benefits in terms of quality of care and quality of life.

Research indicates the need for change in the policy and programs for long-term care in the United States, even as the demand for the services increase and the nursing staff decline. There is a need for the improvement in the various quality-of-life domains, including comfort, security, relationships, significant activity, pleasure, self-respect, independence, privacy, spiritual well-being, eccentricity, and functional competence (Veenhoven, 2013). However, regardless of the identification of this criticality, it is evident that research has not adequately established the indicators of quality that should be observed. There is also a limitation in terms of the actual steps that should be taken to improve the quality. As a result, there is a need for further research into the issues/factors associated with quality of care in nursing homes and the necessary measures that, if taken, will enhance not only the quality of care but also the quality of life for the elderly citizens. The gaps in research are the basis for the proposal of the current study, whose findings will inform policies towards improvement of long-term care.

Research Questions

The overarching research question for the study is:

  1. What are the factors that affect the quality of care in long-term care settings (nursing homes)?

The specific research questions are:

  1. Do staffing shortages affect the delivery of patient care?
  2. Would patient identifiers, such as armbands with patient demographics, affect the delivery of care for residents?
  3. Do government regulations and reimbursements affect the delivery of patient care?
  4. Does the telehealth services help improve the delivery of care to the residents?
  5. How long have you been employed here?
  6. Is it hard to keep residents safe because of staffing issues?
  7. Is there enough staff to handle the day to day workload?
  8. Would an upgraded Electronic medical record system help improve the delivery of care?
  9. Does the telemedicine services increase or improve the access of care for the residents?
  10. Is Respite Care an asset for the elderly residents?
  11. Would home based care help improve the delivery of care for elderly population?


The study will assume a quantitative research approach, with data being collected using two main approaches. The first approach to data collection for the study will be secondary data on government regulations and reimbursements. For the purpose of identifying the role played by government regulations and reimbursements on the quality of care in long-term care facilities, there will be a review of records and reports from the government agencies and the nursing homes selected as the settings for the study. The information will provide the researcher with the insight into the role of these factors to answer the research question and provide evidence for the criticality of improvement. Secondary data from the nursing homes will also be critical to providing insight on other issues relating to the research such as the effect of outdated electronic health systems in the delivery of care.

The second quantitative approach that will be assumed will be the survey. The survey will be carried out on the sample of nurses obtained from the nursing homes; the setting for the study. The nurses will be involved in the study because they are better placed to answer most of the research questions associated with the issue affecting the quality of care in their work settings. The data from the nurses will be collected using a survey questionnaire which will be filled and given back to the researcher for the data analysis. The questionnaire will contain information relating to the research questions, which will include the role of government reimbursements in patient care, the impact of staffing shortages on patient care, the use of telehealth services and impact on the delivery of care, and the impact of patient demographics in delivery of care.


Task August 2017 Sept  2017 Oct 2017 Nov 2017 Dec 2017  Jan 2018
Planning for the project            
Ethical approval            
Design and methodology proposal            
Data collection            
Data analysis            
Report writing            

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