University of Nebraska Medical Center

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Capstone Experience Master of Public Health

5-2023

A Systematic Literature Review on Long-Term Care Quality

Improvement Initiatives in the United States
Daisy D. Pang
University of Nebraska Medical Center

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 1

A Systematic Literature Review on Long-Term Care Quality Improvement Initiatives in

the United States

Daisy D. Pang, Public Health Administration and Policy

Committee:

Dr. David W. Palm, PhD (Chair)

Stephen M. Peters, MA (Committee Member)

Dr. Jungyoon Kim, PhD (Committee Member)

Dr. Hyo Jung Tak, PhD (Committee Member)

 2

Abstract

As the number of people 65 and older increases due to the baby boomer population, there

will be a greater demand for long-term care (LTC) services. Quality improvement in LTC is

essential to ensure positive health outcomes, patient satisfaction, and reduction in healthcare

costs. The purpose of this systematic literature review is to identify the current quality initiatives

for LTC in the United States and evaluate the outcomes, effects, and values of each quality

initiative identified to support the claim that current the quality initiatives have a limited effect

on quality improvement in LTC settings. The Preferred Reporting Items for Systematic Reviews

and Meta-Analyses (PRISMA) approach was used to determine which peer-reviewed journal

articles were going to be included. After analyzing the journal articles, the quality initiatives

identified included implementing increasing the use of advanced practice registered nurses

(APRNs), increasing staff training and education, improving communication between healthcare

providers, incorporating telehealth for palliative care, providing online long-term care resources,

and implementing infection prevention and control programs. These quality initiatives showed

positive results in decreasing emergency room visits, decreasing catheter-acquired urinary tract

infections (CAUTIs), decreasing hospitalizations, and increasing Medicare star ratings. A few

recommendations surrounding the need for having standardized quality initiatives and measures,

increasing research on the effects of the current initiatives, increasing funding, and changing

health policies were incorporated to improve the current issues surrounding quality improvement

initiatives in LTC.
 3

Introduction

Long-term care (LTC) includes a variety of services for people who are unable to

perform basic activities of daily living on their own. Such activities include bathing, dressing,

eating, and moving around. Those who need long-term care are typically the elderly, the

disabled, or people who have serious health conditions such as heart attack or stroke. Long-term

care can be provided in different settings such as home-based care, community-based care, and

facility-based care (National Institute on Aging, 2017). As the population in the United States

continues to get older, long-term care is going to be an important part of the health care system.

According to the U.S. Census Bureau, data shows that the 65 and older population has been

rapidly growing since 2010 due to the aging of the “Baby Boomers” born between 1946 and

1964 (2021). It also states that the national median age has grown from 37.2 years in 2010 to

38.4 years in 2019 (2021). Additionally, as part of the ACA mandate, CMS-certified nursing

homes will be required to implement a program to improve quality of care (Mills et.al., 2018).

With the growing need of LTC services and the lack of quality care in these facilities, the

purpose of this systematic literature review is to identify the current quality initiatives for nursing

homes in the United States. The aim of this paper is to evaluate the outcomes, effects, and values

of each quality initiative identified to support the claim that current quality initiatives have a

limited effect on quality improvement in LTC settings. The two questions that will guide my

paper are:

1. What initiatives are currently in place to improve quality in nursing homes in the United

States?

2. What are the health outcomes of nursing home residents due to the implementation of

quality improvement initiatives?

 4

Background

According to The World Bank, 57 million people, 17% of the world’s population was 65

and older in 2021(World Bank, 2022). It was also estimated that the number would almost

double to 95 million by 2060 (Mather et al., 2015). As these older adults develop serious health

conditions and are unable to care for themselves, they will need to seek out nursing home care.

As of 2021, there is about 1.1 million people in nursing facilities in the United States and that

number is expected to grow (Kaiser Family Foundation, 2022).

LTC provides a range of health care and personal care services. The services offered

typically include nursing care, 24-hour supervision, daily meals, and assistance with everyday

activities. Nursing homes may also provide rehabilitation services, such as physical therapy,

occupational therapy, and speech therapy. Although some people stay at a nursing home for a

short time after being hospitalized, most nursing home residents live there permanently because

their medical condition may require constant care and supervision. (“Residential facilities,

assisted living, and nursing homes”, 2017).

Payers for long term care

The common payers for LTC facilities include Medicare, Medicaid, Veterans Affairs

(VA) insurance, and private LTC insurance. Medicare is a federally funded program and offers

health care coverage for people 65 years or older, people with disabilities, and people who have

end-stage renal disease requiring dialysis or a kidney transplant (U.S. Centers for Medicare &

Medicaid Services, 2021). Medicare coverage is very limited for nursing homes as it only

provides coverage up to 100 days in a skilled nursing facility if the patient is hospitalized for a

minimum of three days and requires skilled nursing for the injury or illness they were
 5

hospitalized for (U.S. Centers for Medicare & Medicaid Services, 2022). With this rule, LTC

facilities may not want to accept patients with Medicare, and it promotes patients to continue to

have poor health so that their care is covered by Medicare.

Medicaid is a federal and state funded program that provides health insurance for low-

income families, pregnant women, children, and individuals receiving Supplemental Security

Income (SSI). Since Medicaid is both a state and federal program, eligibility of coverage can

differ based on requirements of the different states. Additionally, Medicaid will only pay for

nursing home services that are provided in a licensed nursing home and certified by the state as a

Medicaid Nursing Facility (Medicare.gov, n.d.). Despite all the requirement to be eligible for

Medicaid, Medicaid is the largest payer of nursing home services in the United States. In 2016, it

was estimated that 62 percent of people in nursing homes had Medicaid as their primary payer

(Harrington et.al., 2018).

The VA offers coverage for long-term care services in nursing homes to sick or disabled

veterans if they are signed up for VA health care, need a specific service to help with ongoing

treatment and personal care, and the service is available near them (“Geriatrics and Extended

Care”, 2022). The VA only covers care provided by facilities run by the VA or by state or

community organizations that are inspected and approved by the VA. A co-pay for the services

given may be required depending on the resident’s VA service-connected disability status and

income. If the resident has other health insurance policies besides Medicare, they will be billed

and can potentially reduce the co-pay from the VA.

In addition to government funded LTC insurance, private LTC insurance is another type

of insurance that LTC residents have. It can help pay for various long-term care services

including both skilled and non-skilled care. Long-term care insurance can vary depending on the
 6

plan and coverage, and some policies may cover only nursing home care, but others may include

coverage for other services such as adult day care and assisted living (Medicare.gov, n.d.). With

the varied means for the aged to receive LTC, from private care, public care, and home care,

there is often no standard of quality to measure due to the many forms of LTC. Due to the varied

options for care and LTC insurance, it can create inconsistent quality measures and standards.

Conditions and living standards

It is common for nursing homes to see large numbers of infections and injuries acquired

by their residents. A few examples of infectious outbreaks in nursing homes include pneumonia,

influenza, hepatitis B, norovirus, Clostridioides difficile (C. diff), urinary tract infections (UTIs),

and streptococcus (“Serious Infections and Outbreaks Occurring in LTCFs”, 2020). Falls are one

of the most common injuries in nursing home facilities in which approximately half the

population in nursing homes fall annually (“The Falls Management Program: A Quality

Improvement Initiative for Nursing Facilities”, 2017). Additionally, about 1 in 3 of those who

fall will fall more than once in a year. These infections and injuries can lead to serious conditions

that reduce quality of life, ability to function, and negatively impact healthcare outcomes.

Importance of quality care

Because of these risks, it is critical for nursing home facilities to provide high quality

care. The World Health Organization (WHO) defines quality of care as the degree to which

health services increase the likelihood of desired health outcomes. It also states that quality

health care should be effective, safe, and people centered (n.d.). According to the Agency for

Healthcare Research and Quality, “Poor quality care leads to sicker patients, more disabilities,

higher costs, and lower confidence in the health care industry” (“The challenge and potential for
 7

assuring quality health care for the 21st century”, 2018). A few reasons for poor quality are due

to underuse, overuse, misuse, and variation in use of health care services. All these reasons

contribute to the need to improve the quality of care in nursing homes in the United States to

improve health outcomes and reduce healthcare costs.

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Methods

The databases used in this systematic literature review included Medline, PubMed, and

CINALH. The key words used for the database search included nursing home care, quality

improvement, health outcomes, and patient satisfaction. These key terms were selected to

identify the most peer-reviewed journal articles that identified various quality improvement

initiatives in nursing homes and discussed the health outcomes of those initiatives. Patient

satisfaction was included in the key terms because patient satisfaction is a key factor in

influencing the quality of care received and the health outcomes of LTC residents. Table 1

breaks down the databases and key terms used to identify peer-reviewed academic journals.

Table 1
Databases and Key Terms
Databases:
Medline, PubMed, and CINALH
Key Terms:
“Nursing home care”
“Quality improvement” and “nursing homes”
“Nursing homes” and “health outcomes”
“Nursing homes” and “patient satisfaction”

A search criterion was first established to ensure the quality and consistency of the

literature reviewed. Inclusion and exclusion criteria were identified to narrow down the number

of articles that would be the most useful for this literature review (see table 2). The literature

used in this review was limited to academic peer-reviewed journals and publications that were

published from January 2017 to January 2023. The peer-reviewed journals were also reduced to

studies done in the United States and written in the English language. Both quantitative and
 9

qualitative studies were included in the literature review. The most important criterion was that

the publication needed to discuss the health outcomes of the quality initiatives.

Table 2
Inclusion and Exclusion Criteria
Criteria Inclusion Exclusion

Results/Outcomes • Quality improvement • No change in quality

in resident care improvement
• Improvement in • Decrease in quality
health outcomes • Negative health
• Increase patient outcomes
satisfaction
Publication Type • Full articles • Non-academic journal
• Academic journal articles or
articles publications
• Peer-reviewed • Abstracts only
journals
• Quantitative
• Qualitative
Publication Date • Published after 2017 • Published before 2017

Language/Geography • Studies done in the • Studies done outside

United States the United States
• English language • Non-English language

Literature Search Strategy

After the search criteria were established, the key terms were searched and filtered in

each of the databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses

(PRISMA) approach was used to identify and exclude publications that did not meet the

established criteria. The first search included all publications that resulted from each keyword

search. Then, the publications were filtered by the publication type, publication day, location of

the publication, and language. After they were narrowed down by the search criteria, the titles
 10

and abstracts of each journal article were reviewed to identify which publications could

potentially be included in the literature review. The full text of the journal articles that met all the

criteria was read to determine which studies would ultimately be used.

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Results

The initial literature searches from Medline, PubMed, and CINALH resulted in 19,015

articles. After filtering the initial searches with the established criteria (see Table 2), 2,120

articles were identified to meet the criteria. After removing duplicate articles, 56 articles were

reviewed by title and abstract to identify the potential articles that would be included in the

literature review. Of the 56 articles, only 11 articles discussed successful quality initiatives in

LTC setting with positive health outcomes. Figure 1 below shows the PRISMA breakdown of

the literature search for this systematic literature review.

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Figure 1. PRISMA breakdown of how articles were chosen.

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After reviewing each of the 11 articles, the different themes associated with the quality

initiatives were identified. The themes pursued in the articles included implementation of quality

improvement (QI) frameworks, communication, teamwork, use of advance practice registered

nurses (APRNs), cost effectiveness, staffing shortages, infection control, staff training and

education, telehealth, online resources and tools, emergency preparedness, and clinical

documentation (see Table 3). From these themes, the common quality initiatives to purse the

improvement of these themes included increasing the use of APRNs, increasing staff training and

education, improving communication between healthcare providers, incorporating telehealth for

palliative care, providing online long-term care resources, and implementing infection prevention

and control programs.

Table 3.
Themes associated with each peer-reviewed journal article
Title Author(s) Themes

A National Implementation Mody, L., Greene, M. T., • Infection prevention

Project to Prevent Catheter- Meddings, J., Krein, S. L., and control
Associated Urinary Tract McNamara, S. E., Trautner, • Staff education and
Infection in Nursing Home B. W., Ratz, D., training
Residents Stone, N. D., Min, L.,
Schweon, S. J., Rolle, A. J.,
Olmsted, R. N., Burwen, D.
R., Battles, J., Edson, B., &
Saint, S.
APRN-Conducted Vogelsmeier, A., Popejoy, L., • Use of APRNs
Medication Reviews for Crecelius, C., Orique, S., • Medication errors
Long-Stay Nursing Home Alexander, G.L., & Rantz, M.
Residents (2017).

Call to action: APRNs in U.S. Rantz, M. J., Birtley, N. M., • Use of APRNs
nursing homes to improve Flesner, M., Crecelius, C., & • Cost effectiveness
care and reduce costs Murray, C. • Staffing shortage
 14

Wittenberg, G. F., Reddy, A., • Infection prevention

Design of a Nursing Home Gifford, D. R., McLaughlin, and control
Infection Control Peer M. M., Leung, V., & Baier, • Staff
Coaching Program R. R. training/education
• Teamwork

Development of a Palliative Baxter, K. E., Kochar, S., • Telehealth

Telehealth Pilot to Meet the Williams, C., Blackman, C., • Staffing shortage
Needs of the Nursing Home & Himmelvo, J.
Population.

Economic Evaluation of a Hutton, D. W., Krein, S. L., • Infection prevention

Catheter-Associated Urinary Saint, S., Graves, N., Kolli, and control
Tract Infection Prevention A., Lynem, R., & Mody, L. • Staff
Program in Nursing Homes training/education
• Cost effectiveness
Impact of Nurse Practitioner Bakerjian, D., & Dharmar, M. • Use of APRNs
Care of Nursing Home
Residents on Emergency
Room Use and
Hospitalizations
Implementation of Florida Blake, S. C., Hawley, J. N., • Online resources/tools
Long Term Care Emergency Henkel, A. G., & Howard, D. • Emergency
Preparedness Portal Web H. preparedness
Site, 2015–2017 • Communication

Improving Communication in Kay, S., Unroe, K. T., Lieb, • Staff

Nursing Homes Using Plan- K. M., Kaehr, E. W., training/education
Do-Study-Act Cycles of an Blackburn, J., Stump, T. E., • Communication
SBAR Training Program Evans, R., Klepfer, S., & • Teamwork
Carnahan, J. L. • Clinical
documentation

Nursing Home Infection Stone, P. W., Herzig, C. T., • Infection prevention

Control Program Agarwal, M., Pogorzelska- and control
Characteristics, CMS Maziarz, M., & Dick, A. W. • Staffing shortage
Citations, and • Staff
Implementation of Antibiotic training/education
Stewardship Policies: A
National Study.
 15

Vogelsmeier, A., Popejoy, L., • Implementation of QI

Results of the Missouri Canada, K., Galambos, C., framework
Quality Initiative in Petroski, G., Crecelius, C., • Teamwork
Sustaining Changes in Alexander, G.L., & Rantz, M. • Use of APRNs
Nursing Home Care: Six-
Year Trends of Reducing
Hospitalizations of Nursing
Home Residents

Use of advance practice registered nurses (APRNs)

With a decline in physicians specializing in geriatrics, implementation of full-time

APRNs in nursing homes would be beneficial to reduce unnecessary hospitalization for nursing

home residents by providing a focus on care delivery, early illness detection, acute illness

management, medication review, and systems change (Vogelsmeier et.al., 2021). In addition to a

reduction in hospitalization, APRN care in nursing homes can reduce emergency room visits and

Medicare expenditures. Care provided by APRNs has been shown to be cost effective, safe, and

results in positive health outcomes and increased patient satisfaction (Rantz, et.al., 2017). A

study involving a 5% random sample of all nursing homes in the United States, showed that

patients nurse practitioner (NP) involvement (mean = 2.1) had fewer emergency department

(ED) visits with a mean of 1.1 less visits compared with physician only care (mean = 3.2)

(Bakerjian & Dharmar, 2017). This study shows that NPs, a type of APRN, can significantly

reduce the use of the ED and acute hospitalizations by improving the health of residents during

routine visits.

An additional study described how APRNs conducted medication reviews for long-stay

nursing home residents and made recommendations for medication order changes to physicians.

During the two-year study, 50% of the 19,629 reviews resulted in a recommendation for order
 16

change by APRNs and 82% of those changed recommendations (n=8037) occurred (Vogelsmeier

et.al., 2017). This study resulted that due to the advanced pharmacology education and daily

presence of APRNs in nursing homes, it ensures that the prescribed medications align with the

health goals of the residents and reduces the potential for harm due to the need of medication

adjustments and/or discontinuation.

Staff training and education

Continuous education and ensuring staff are up to date on current practices, procedures,

and policies are crucial to providing quality care for nursing home residents. Staff training and

education are typically incorporated into nursing homes when new programs and quality

improvement initiatives are created. When a nursing home infection control peer coaching

program was introduced into nursing homes in Connecticut, an infection preventionist worked to

identify peer coaches within staff members to provide real-time feedback on infection control

practices (Wittenberg et.al., 2023). Peer coaches had the role of educating co-workers on

infection control practices and provided corrections or praises when needed. Another study

evaluating the impact of a catheter-associated urinary tract infection (CAUTI) prevention

program created an interactive educational program for reducing multidrug-resistant organisms

(MDRO) and device-associated infections and promoting proper hand hygiene (Hutton et.al.,

2018). This education resulted in a 31% reduction in all clinically diagnosed CAUTIs and 8.7

fewer CAUTIs per nursing home per year.

Communication between healthcare providers

Improving communication between healthcare providers can reduce errors and improve

the quality of care given to patients in nursing homes since incomplete communication can cause
 17

negative outcomes. A situation-background-assessment-recommendation (SBAR) training

program was implemented in Indiana nursing homes to improve communication surrounding

changes in the residents 'conditions and improve nursing documentation (Kay et.al, 2022). SBAR

is a tool intended to help improve clinical communication and to promote nurses to make

recommendations based on assessments and patient background. Establishing a standard handoff

communication tool improves patient safety by decreasing the risk for incomplete, inaccurate,

and delayed information.

One change that was made in the training program was adapting the standard SBAR into

the Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms:

Transforming Institutional Care (OPTIMISTIC) program is in partnership with the CDC. The

OPTIMISTIC adaptation is more beneficial for nursing homes because it allows for geriatric and

palliative care trained registered nurses and nurse practitioners to collaborate with nursing home

facilities to improve early recognition of condition changes, transitions to and from the hospital,

and advanced care planning. Although there were no specific outcome values, the

implementation of this quality improvement initiative led to an increased use of the SBAR tool,

improved documentation, and increased the collaboration between healthcare providers in the

participating nursing homes. It was also successful in reducing hospitalizations and hospital

transfers for long-term care residents (Kay et.al, 2022).

Telehealth for palliative care

Nursing home residents with unclear goals of care are at higher risk of rehospitalization

and often experience an increase in poor care at the end of life. However, conversations with

residents about illnesses and wishes for care are not happening consistently across nursing home

facilities. Time restraints and lack of formal training in advanced care planning, goals-of-care,
 18

and end-of-life discussions are reasons why some nursing home facilities are not providing these

services to residents (Baxter et.al., 2021). Making palliative care clinicians who are trained in

discussions regarding advanced disease, goals of care, prognosis, and symptom management

accessible can improve the goals of care and identify the needs of the residents in nursing homes

(Baxter et.al., 2021).

Despite the need for palliative care services, access to these services is inadequate

because palliative care clinicians are limited nationwide and found primarily in acute care

settings. The implementation of telehealth palliative care is a quality improvement initiative that

has been introduced to connect residents to palliative care clinicians remotely through

telecommunications (Baxter et.al., 2021). A telehealth palliative care pilot program study done

by Baxter et.al., found that of the 21 patients who received palliative care consults, none were

hospitalized during the pilot (2021). However, of the 20 consultations that were canceled, 70%

were hospitalized. This result shows that the incorporation of telehealth palliative care services

can reduce hospitalization.

Online long-term care resources

The availability of online long-term care resources is another quality improvement

initiative that has been introduced. One example of online long-term care resources is in the State

of Florida. The Florida Long Term Care Emergency Preparedness Portal was created with the

help of the Florida Health Care Association (FHCA) and Florida Department of Health (Blake

et.al., 2018). The purpose of the portal was to improve disaster preparedness among LTC

providers by developing an online tool that strengthens communication and collaboration among

the LTC providers, public health organizations, and emergency management communities. The
 19

online tool provides users access to information related to national and state preparedness

planning and response, emergency preparedness training, and disaster recovery.

The article did not mention specific values of how the resources have improved health

outcomes of nursing home residents. However, it indicated finding from the surveys that nursing

home administrators completed (288 responses). The results of the survey showed that

approximately 61.7% used the portal at least monthly or occasionally. 71.7% of respondents

rated it as a good resource for LTC emergency preparedness planning. Respondents also

indicated that although the portal had good information, it was difficult to find key resources.

Infection prevention and control programs

The Centers for Medicare & Medicaid Services (CMS) requires that nursing homes

develop an infection control program that includes an antibiotic stewardship component and

employs a trained infection preventionist (Stone et.al., 2018). This requirement has influenced

the implementation of infection prevention and control programs to improve the quality of care

and health outcomes in nursing homes. Infection prevention and control programs are important

to implement because it assists facilities in preventing, diagnosing, and managing infections.

Nursing homes have a greater need for these programs due to the high-risk population and the

large number of shared spaces in nursing homes.

The Agency for Healthcare Research and Quality (AHRQ) funded a national infection

prevention project in the nursing home setting to develop and implement interventions to reduce

CAUTIs (Mody et.al., 2017). Technical and socioadaptive interventions were combined to

educate on infection prevention and control strategies, empower facility teams, and address

implementation barriers. Evidence based education on hand hygiene, prompt removal of

 20

unnecessary catheters on admission, catheter maintenance and insertion, reducing inappropriate

catheter use, and considering alternatives to indwelling urinary catheters were included in the

infection prevention project. CAUTI rates from 368 participating nursing homes decrease from

6.42 per 1000 catheter days prior to the project to 3.33 per 1000 catheter days at the end of the

project. 75% of the participating nursing homes reported at least a 40% reduction in CAUTIs in

their individual facilities. Additionally, the overall Medicare stars rating among participating

nursing homes increased by 0.02 points.

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Discussion

In this systematic review, there were six nursing home quality initiatives introduced.

Those initiative were to increase the use of APRNs, increase staff training and education,

improve communication between healthcare providers, incorporate telehealth for palliative care,

provide online long-term care resources, and implement infection prevention and control

programs. After identifying the different values of each health outcome (see Table 4), the

initiatives with the best outcomes were the use of APRNs, implementing telehealth palliative

care services, and increasing infection prevention and control programs. The use of APRNs were

successful in reducing the number of ER visits and ensuring the right medications and dosages

were given to nursing home residents. This not only improves the health of the residents, but it

reduces the costs that residents face from ER visits and the use of unnecessary medications.

Implementing telehealth palliative care services is another initiative with one of the best

outcomes because the study showed those who participated in palliative care consultations had a

0% hospitalization rate compared to a 70% hospitalization rate for those who had cancelled their

consultations during the pilot period. With the use of telehealth palliative care services, it

decreases costs associated with having an in-house palliative care service, reduces hospitalization

rates, and increases the overall health of the residents.

Table 4.
Activities, outcomes, and values of each quality improvement initiative
Initiative Activity Outcome Value
Use of APRNs • Incorporated the • Decreased the number • Reduced ER
use of daily nurse of ER visits visits from 3.2 to
practitioners in • Recommendations lead 2.1 visits
addition to to a change in • 82% of
physician visits medications recommendations
given to
 22

• APRNs conduct physicians

medication occurred
reviews
Increase staff • Infection • Reduction on CAUTIs • Clinically
training and preventionists diagnosed
education trained peer CAUTIs reduced
coaches on by 31%
infection control • 8.7 fewer
practices to CAUTIs per
provide serve as nursing home
a resource and annually
train other staff
Improve • Use of SBAR • Improved • N/A
communication documentation
between • Increase collaboration
healthcare between healthcare
providers providers
• Decrease
hospitalizations/hospital
transfers
Implement • Piloted a • Decrease in • 0%
telehealth telehealth hospitalization hospitalization
palliative care palliative care rate in nursing
program in homes that
nursing homes utilized telehealth
palliative care
• 70%
hospitalization
rate in those who
cancelled
consultation
Incorporate • Florida LTC • Increase use in • 61% of nursing
online LTC Emergency resources home
resources Preparedness administrators
Portal used monthly or
occasionally
• 71% rated
resources as good
Increase • AHRQ national • Decreased the number • CAUTI rate
infection control prevention of CAUTIs decreased from
and prevention program using • Increase Medicare stars 6.42 per 1000
technical and rating catheter days to
socioadaptive 3.33
infection • Overall Medicare
prevention stars increase of
interventions 0.02 points
 23

Although all these initiatives had a positive impact in one way or another, they produced

average outcomes and had limitations to their initiatives. One limitation to the use of APRNs is

that Medicare reimbursement for APRNs is negatively affecting nursing homes from

implementing this intervention. APRNs can only directly bill Medicare if they are supervised by

a physician. If they bill indirectly and care is not provided under a physician, reimbursement

from Medicare is only 85% of a physician’s rate (Rantz, et.al., 2017). As a result, nursing homes

have been reluctant to hire APRNs directly which has reduced the residents’ access to timely and

quality care. Therefore, this endorsed the need for policy change to increase reimbursement rates

for nurse practitioners to promote the use of APRNs in LTC facilities.

A limitation to the implementation of staff training and education to improve quality of

care are the lack of feedback given to staff, being short-staffed, and staff not making changes

despite the education programs. To successfully implement and see changes from training and

education, nursing homes need to be fully staffed for employees to follow through with the

education they receive. Also, if there is not continuous check-in to observe if staff are following

new practices, procedures, and policies, no improvement will be made if staff are not motivated

nor independent. Ultimately, this can lead to a waste of resources, no improvement in the quality

of care, and worse patient health outcomes.

The lack of staffing and limited time for quality communication and documentation are

barriers to successfully implementing communication tools to improve communication between

healthcare providers. Providers are prioritizing seeing more patients than spending time on

documentation. Due to this issue, timely and quality documentation for residents is not always

being completed, which affects the quality of their health due to incomplete, inaccurate, and

delayed handoff of health information to other providers.

 24

Similarly for infection prevention and control programs, one limitation is that nursing

homes are understaffed. When nursing homes are understaffed, these programs may become

neglected, or healthcare providers may not be able to help with infection management decisions.

Another limitation is that older residents may not have the same symptoms as younger adults and

their ability to communicate their symptoms to healthcare providers may be difficult (Stone

et.al., 2018). This can delay identification of illnesses and care given to residents, resulting in an

increase in hospital transfers, increased costs, and negative health outcomes for the nursing home

residents.

In addition to the specific limitations for each initiative, there are a few issues identified

with the current initiatives in place. One issue is that there is a variety of quality initiatives

currently being implemented and piloted. This causes an issue of having no standardized quality

initiative that all LTC facilities can implement. The inconsistency with quality measure tools for

various types of LTC can also lead to providers possibly continuing to use the same modestly

effective initiatives that aren’t producing the highest quality of care and health outcomes.

Another issue is that since there is such a variety of quality initiatives, there aren’t a lot of

studies and academic journals published for each initiative to provide evidence that these

initiatives have consistent results. A review by Toles et.al. supports the claim that there is a lack

of published information on QI strategies in nursing homes (2021). They state that “little is

known about how QI strategies are used in NHs, their effectiveness, or how to replicate or apply

proven strategies across settings” (Toles et.al., 2021). They also discuss that QI work in nursing

homes are not published and the reviews that are published are 6-15 years old. Additionally, they

share that evidence from QI studies often have variations in terminology, outcomes

measurement, and how findings are reported across methodologies. This provides support that
 25

there are issues of having limited information regarding quality initiatives in nursing homes,

having variations in quality measurements, and having most of the shared studies being

completed many years prior.

This systematic literature review had a few limitations relating to the criteria and results

identified in the articles included in this literature review. One limitation is that since the studies

were limited to studies done in the United States, there were fewer quality initiative identified

and there were limited articles to include in this review. Another limitation is that many of the

articles were published before 2017, which limited the options that were available to include in

this literature review. Also, with the criteria of having studies only with positive outcomes

included in the literature review, it possibly could have filtered out other quality initiatives that

are currently being used. Lastly, another limitation to this study is that there was a study that did

not include values for their outcomes. The study that supported the use of the SBAR tool only

indicated improved documentation, increased collaboration between healthcare providers, and a

decrease in hospitalizations/hospital transfers. Without specific values of the outcomes, it can

affect the accuracy of the comparison of the initiatives included in this literature review.
 26

Recommendations

Many of the quality initiatives included in this literature review provided evidence that

there are two main issues with the current quality initiatives in LTC. The first issue is that there

is a lack of publications on studies that show the effectiveness of these quality initiatives. The

second issue is that there is a large variety of initiatives with no standardized quality initiatives

that can be implemented across all LTC facilities. Therefore, it is important for healthcare

organizations and providers to allocate more resources and time to identify the best quality

initiatives currently in place through studies and determine a standardize quality improvement

processes that includes a few qualities improvement options for LTC facilities to incorporate into

their organization.

One recommendation is to have a government agency such as the Agency for Healthcare

Research and Quality to identify three quality initiatives and conduct multiple studies in LTC

facilities across the nation to identify which initiative produces the best health outcomes. A plan,

do, study, act (PDSA) model can then be used to implement the chosen initiative into a small

group on nursing homes and identify areas of improvement. Once the initiative has been proven

to have little to no limitation regarding the success of the initiative, it can be implemented across

all the LTC facilities in the nation. After a successful standardized initiative is implemented,

other initiatives can be incrementally added to the list of standardized initiatives for LTC

facilities to use.

Another recommendation is to implement policy changes and increase funding to support

the use of quality improvement initiatives. Without these, healthcare organizations and facilities

lack the encouragement to make quality changes and healthcare in the United States will

continue to be reactive instead of proactive. If we are reactive, healthcare costs will continue to
 27

rise, patient satisfaction will decrease, and the quality of life will decrease. Although policy

changes and additional funding can be challenging, by continuing to provide evidence-based data

and results to those who can influence policy development and provide funding for these

initiatives, it is possible to increase the practice of quality improvement.

 28

Conclusion

The field of quality improvement in healthcare is important in improving our current

healthcare system and advancing the use of public health in the United States. However, there

are barriers to the implementation and success of quality improvement initiatives that need to be

removed. Some examples of barriers include facilities being short staffed, lack of funding for

initiatives, limited education or training, and poor health policies. As more evidence-based data

proving the success of quality improvement initiatives become published and standardized

quality initiatives are identified, it can greatly improve the quality, delivery, and outcomes of

healthcare provided in LTC facilities in the United States. Therefore, this systematic literature

review will help to bring awareness to the issues surrounding quality improvement initiatives in

long-term care facilities in the U.S. Additionally, it brings awareness to how importance public

health’s role in implementing quality improvement initiatives that result in being proactive and

providing quality care.

 29

Application of Public Health Competencies

The following University of Nebraska Medical Center Master of Public Health

competencies were met upon the completion of this systematic literature review:

Foundational Competencies:

MPHF4: Interpret results of data analysis for public health research, policy, or practice

MPHF15: Evaluate policies for their impact on public health and health equity

Concentration Competencies:

HSRAMPH4 - Summarize the legal, political, social, and economic issues that impact the

structure, financing, and delivery of health services

within health systems in the US.

HSRAMPH5 - Examine information about health policy issues and problems, and evaluate

alternative policy options for these issues.

MPHF4 and MPHF15 were accomplished through identifying and analyzing the

outcomes from the long-term care quality initiatives. Each study in the 11 articles included in

this systematic literature reviewed were reviewed to determine the common themes (see Table 3)

and outcome/values of each initiative (see Table 4). HSRAMPH4 was met though identification

of the issues surrounding access, cost, and delivery of healthcare for long-term care residents due

to the lack of support, funding, and standardization of quality improvement. Lastly, HSRAMPH5

was met by identifying limitations of the regulations and policies of the quality initiatives and

discussing a few recommendations. I recommended to change policies to increase funding on

research and implementation of current and new quality initiatives. Another recommendation
 30

was to determine which quality initiatives would result in the best outcomes and to use that

research to create a standard quality improvement program across the nation.

 31

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