Quality of Medical Care and Payment in the Healthcare

Overview, population and problem statement-including setting

Our healthcare system has continuously seen an increase in the ageing population, 65 and older. According to the Institute of Medicine (US) Food Forum, (2010), there exist about 39.5 million people in the United States over 65 years old with 5.6 million over 85 years old. These populations, in addition to its rapid growth, is faced with diseases such as diabetes mellitus, hypertension, coronary artery diseases, obesity, pressure injuries, stroke, and more. It is estimated that about 1.5 million of adults aging 65-and-older live in skilled nursing facilities (SNF) and about 1 million, live in assisted living facilities, (Pray, 2010).

According to the Centers for Disease Control (CDC), 2016, they exist over 15,600 nursing home facilities in the United States (US), with 1.7 million licensed beds.

Patients are often referred to these SNF from the hospital for skilled services after they are being discharged from the hospital. The patient’s functional status and level of home support with activities of daily living (ADLs) prior to illness is usually highly taken into consideration when planning discharge and determining if to be discharged home or to a SNF, (Lage et al.

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, 2018).

Patients who lived alone prior to their illness/hospitalization were “more than twice the odds of being discharged to a SNF” compared to their counterparts who did not live alone and who had home support with ADLs, (Lage et al., 2018). Hence, SNF are like a transition of care from the hospitals to patient homes. According to the U.S Department of Health and Human Services, Nursing homes/SNF, are facilities involved in providing patients with both health and personal services with more emphasize on medical care such as, 24-hour supervision, three meals a day, assistance with ADLs and rehabilitation services (physical, occupational, and speech therapy).

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While these facilities may house patients on a short-term stay, they also provide care and accommodation to other patients on a long-term stay basis, these are mostly patients who have an ongoing physical or mental condition, requiring constant care and supervision, (National Institute on Aging, 2020). Besides the primary diagnosis for admission in to the SNF, most of these elderly residents often already have comorbidities which may limit their ability to be freely mobile, with some being completely bed/chair ridden. The presents of these comorbidities alongside the nature of the SNF may dispose some of them or increase their risk for pressure ulcers (PU).

Epidemiology, Demography, and Impact of the problem, including disparities and disease.

PU also known as pressure injuries (PI) are lesions caused by unrelieved pressure or friction or compression of soft tissue between a bony prominence and an external surface over a prolong period of time, (Berlowitz, 2019). It affects about one fifth of nursing home residents, (Reddy & Reddy, 2011). PU are a common challenge in SNF with about 10 – 35% present on admission, (Berlowitz, 2019). In a study, long term care patients in SNF were found to be at increased risk for PU compared to those who were admitted for short term care services (rehabilitation), (Courvoisier et al., 2018). Almost 80% of the admissions I do at my job (SNF), are status post hip surgery to repair a hip fracture related to a recent fall and research has found that the incidence of pressure ulcers in patients with a hip fracture ranges from 10% – 40%, (Williams et al., 2013).

I can relate to this as these patients at my job sometimes prefer to be immobile for fear of pain resulting from mobility. As a result, most pain pills are ordered as needed 30 minutes before therapy to make sure their pain is under control thereby promoting their participation and compliance with therapy.

While the incidence rate of PU in SNF can be as high as 24%, in another study, the prevalence rate was noted to be generally lower among long-term care residents, (Berlowitz, 2019). Research has found the rate of PU to be significantly higher in men than in women, (Karen et al., 2016). In the same research, African Americans were found to have a significantly higher rate of PU compared to all other races with Caucasians following suit, (Karen et al., 2016).

Prevalence (national, state, and local statistics as available)

The prevalence of PU may vary between facilities. An estimated 2.5 million pressure-induced injuries are treated each year in acute care facilities in the United States alone, (Jehle et al., 2019). In one study, the overall PU prevalence varied between 2.2% and 23.9% and between 3% and 33% for high-risk chronic-care residents, (Courvoisier et al., 2018).

In a study, it was found that while PU prevalence is relatively low, the establishment of programs to focus on the correct use of the recommended preventative measures will help reduce its prevalence as the prevalence has to an extent been linked to the use of these preventive measures, (Courvoisier et al., 2018).

Root cause analysis

Patient Factors

Malnutrition: In one research, nursing home patients were noted to be at a 20% risk for malnutrition, (Fossum et al., 2011). According to the National Institute of Ageing, (2020), the sense of taste may diminish or get lost with aging as a result, this aging population may not eat the necessary foods they need to stay healthy, leading to malnutrition and increased risk for impaired tissue integrity.

Immobility: This may arise from an acute or long-term illness. Patients recovering from a hip fracture are 10% – 40% more prone to PU, (Williams et al., 2013). And over 50% of patients with a hip fracture of often discharged from the hospital to SNF for skilled services, (Williams et al., 2013). This risk of course is higher in long term bed bound or chair bound patients.

Age: In the United States, about 39.5 million people are 65 years old, about 5.6 million are 85 years old, about 1.5 million of those 65 and older live in Skilled Nursing Facilities (SNF) and about 1 million in assisted living facilities, (Pray, 2010). Pressure injury rates increase significantly with age (Karen et al., 2016).

Race and Gender: In a study, the rate of PU was found to be significantly higher in men than in women, and in the same study, African Americans were found have higher rates of PU when compared to patients of other races followed by Caucasians, (Karen et al., 2016). In addition to the above listed patient factors, this population is also faced with comorbidities such as incontinence, hypotension, diabetes and more, (Karen et al., 2016). Some of these disease conditions such as stroke and diabetes have resulted to sensory loss/poor sensory perception, (Williams et al., 2013) and also besides patient position, disposes to reduced skin perfusion: (Berlowitz, 2019)

Provider Factors

Inadequate resources such as understaffing and finances: SNF with limited staffing will not be able to appropriately provide pressure ulcer prevention strategies such as frequent repositioning or taking patient out of bed. Finances/cost mounts additional pressure therefore impacting their ability to afford/implement the necessary preventative practices, (Worsley, 2017). When there is staff shortage, or when staffs are assigned other duties, they turn to prioritization in practice, an example is a staff having other duties as a therapist may take priority over pressure ulcer prevention, (Worsley, 2017).

Some SNF lack access to appropriate equipment’s. Research has found that, the use of special matrasses in patients with hip fracture significantly decreases risk of PU, (Williams et al., 2013). SNF staffs lack training, awareness or education regarding specific pressure ulcer prevention equipment, (Worsley, 2017). While reduced skin perfusion: (Berlowitz, 2019) was noted to one cause of PU, frequent repositioning can help improve circulation and prevent skin break down.

System Factors

An estimated 2.5 million pressure-induced injuries are treated each year in acute care facilities in the United States, (Jehle et al., 2019). About $11 billion dollars is spent on pressure ulcers yearly, with $500 to $70,000 being spent on a single wound, (Boyko et al., 2018). The Centers for Medicare and Medicaid Services (CMS) has begun penalizing facilities with new PU by not paying for facility acquired PU while providing incentives to facilities for prevention and quality patient care, (Boyko et al., 2018).

Discussion of which root causes should be addressed and why

While it may be impossible to address some patient factors (age, gender, race and comorbidities), it is possible for one to address most provider factors such as education, equipment, understaffing, finances and more. These provider factors work hand in hand with each other. Finances are needed to hire qualified staffs and purchase the necessary items to prevent ulcers such mattresses, pressure relieving boots, and more. However, purchasing these without having the trained/educated staffs to implement them appropriately will be waste of time and resources. PU prevention requires a teamwork approach and with the lack of communication amongst the multidisciplinary team and management, this goal cannot be met (Worsley, 2017).

The cost of treating PU outweighs the cost of prevention as prevention was seen to result in cost savings of 99.99%, (Padula et al., 2011). In this same study, while the expected cost of prevention was $7276.35, and the expected effectiveness was 11.241 QALYs, the expected cost for standard care was $10,053.95, and the expected effectiveness was 9.342 QALYs, (Padula et al., 2011). The threshold cost of prevention was $821.53 per day per person, whereas the cost of prevention was estimated to be $54.66 per day per person, (Padula et al., 2011). It is estimated that up to 60 000 Americans die each year as a direct result of pressure ulcer-related complications. PU have been proven to negatively impact the quality of life of these patients and has substantially contributed to increased rate of mortality, pain, psychological stress, increased family burden and even loss of work, (Karen et al., 2016).

Clinical quality measures

PU according to the CMS and Agency for health care research and quality continue to be a quality care indicator with penalties being levied over facilities with facility acquired PU through none reimbursement. The Institute for Healthcare Improvement, (2019), reports most pressure ulcers as being preventable meaning they are some PU that can not be prevented. While it has been easy to determine facility acquired PU from those present on admission, it remains a challenge to ascertain how the CMS determines which PU are deemed preventable which ones are not preventable in relation to reimbursement.

Appropriate implementation and evaluation of PU preventive measures were deemed helpful in preventing PU, (Hommel et al., 2017). In a research, it was determined that PU can be successfully prevented via the ‘creation of good organization, maintaining persistent awareness and realizing the benefits for patients, (Hommel et al., 2017). The usage of different evaluation methods without any standardized procedure may lead to inaccuracy of data.


According to the US census bureau, (2019), 18.7% of people living in group quarters between 2014-2018 were 65 years and older with 82.0% of this population living in SNF. PU in the elderly in these facilities have been highly associated with a diagnosis of malnutrition, hypotension, incontinence, diabetes and more, (Karen et al., 2016). The Agency for Healthcare Research & Quality (AHRQ) estimates that more than 2.5 million individuals in the US develop pressure ulcers annually, (Karen et al., 2016).

While it is a quality indicator of care, the CMS new reimbursement rule of “pay for performance,” no longer allow reimbursement to facilities for PU acquired at facilities after admission, thus encouraging reimbursement only to facilities that meet certain standards of care, (Boyko et al., 2018). Besides all the efforts put forth, PU remains an ongoing challenge in healthcare especially in terms of reducing harm to patients. Several innovations to prevent PU have been put forth such providing, oral nutritional supplement repositioning, using standardizing documentation procedures, and more, (Courvoisier et al., 2018).

It may seem contradictory as well in assessing risk factors because as mentioned above that nursing home size, patients’ age or length of stay, are a major risk factor, a 2017 research found that the presents of PU is associated with the patients braden scale, with higher score indicative of higher risk compared to patients with lower scores, (Blenman et al., 2017). Pressure ulcers negatively impact patient health by increasing morbidity and mortality rate, and increases in healthcare cost both to the patient, family and, the health care system, (Karen et al., 2016).

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Quality of Medical Care and Payment in the Healthcare. (2022, Jun 04). Retrieved from https://studymoose.com/quality-of-medical-care-and-payment-in-the-healthcare-essay

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