LETTER
OBRA Regulations for Nursing Homes—Enhancing Paperwork or Patient Care?
Valery A. Portnoi, MD
1 November 1994 | Volume 121 Issue 9 | Pages 724-725
TO THE EDITOR:
In their commendable review [1], Ouslander and Osterweil describe extensive physician responsibilities but confess that the cost-effectiveness and efficiency of these practices for preventing morbidity and death in nursing homes have never been tested. Instead, the authors rely on guidelines of federal rules for nursing homes, particularly the Omnibus Budget Reconciliation Act (OBRA) of 1987 [2]. The authors do acknowledge that OBRA regulations will be difficult to implement in light of the negative "nature of the nursing home environment" and inadequate Medicare reimbursement for physician care.
Medical practice cannot be neatly regulated by government, nor will extensive regulation be an asset in attracting the best physicians to the field of geriatrics. I believe that we should maximize nursing home residents' potential for returning to the community and should prevent unnecessary hospitalizations. Development of a medical unit [3] for the care of acute medical problems within nursing homes might accomplish the latter goal. All systemic infections (short of overwhelming sepsis), uncomplicated cardiac and cerebral vascular events, deep venous thrombosis, and many disorders that traditionally require hospitalization could be treated in such a unit. It would be particularly appropriate for patients with do-not-resuscitate orders. Just treating acute urinary tract infections and pneumonia in nursing homes could prevent more than 2000 hospitalizations nationwide, with savings of more than $1 billion [4].
The diagnosis-related group regulations have freed physicians to prematurely discharge hospitalized patients. As a result, many acutely ill elderly are transferred to nursing and home care facilities that are poorly prepared to care for them. These regulations have exacerbated problems with continuity in our antiquated health care system for the elderly [5]. The nursing facility is only one of many components of an integrated, multilevel system that includes day care, day hospitals, home health care, hospice, respite care, geriatric assessment clinics, and rehabilitation units. A multidisciplinary geriatric medical team working in concert would assure continuity of care within the system.
1. Ouslander JG, Osterweil D. Physician evaluation and management of nursing home residents. Ann Intern Med. 1994; 120:584-92.
2. Eson R, Pawlson LG. The impact of OBRA on medical practice within nursing facilities. J Am Geriatr Soc. 1992; 40:958-63.
3. Gordon M, Chenng M, Wiesenthal S. An acute care unit in a multilevel geriatric facility: the first two years of the New Baycrest Hospital. J Am Geriatr Soc. 1990; 38:728-30.
4. Brooks S, Warshaw G, Hasse L, Kues JR. The physician decision-making process in transferring nursing home patients to the hospital. Arch Intern Med. 1994; 154:902-4.
5. Portnoi VA. A health-care system for the elderly. N Engl J Med. 1979:300:1387-90.
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