Nurse assignment consistency is vital

An aide notices an untouched cup of coffee sitting on the bedside table near an elderly resident I will call Mrs. Jones.

This break in the routine troubles the nursing home aide, who has been caring for Mrs. Jones for three years. She knows, for example, that this resident loves her morning coffee. So she offers to bring her a hot cup.

But Mrs. Jones just shakes her head and says she doesn't feel up to it.

As it turns out, Mrs. Jones is in the early stage of a heart attack and the untouched coffee, as insignificant as it seems, has alerted the nurse that something is wrong. She pages the doctor and Mrs. Jones gets prompt—and possibly life-saving—medical care.

Similar situations play out again and again in nursing homes that assign an aide or a nurse to regularly care for an elderly, frail resident. The practice is called "consistent assignment," and it is one key target identified by Advancing Excellence in America's Nursing Homes, a 3-year-old national campaign aimed at improving the quality of nursing-home care.

To date, 42% of the nation's nursing homes have joined the campaign, which is the largest voluntary effort of its kind in the industry. But administrators of all 16,000 nursing homes in the U.S. should sign up today and pledge to make quality care a top priority.

Nursing homes that join the campaign set quality targets, and they can monitor their performance. The campaign works to help nursing homes improve by giving them important tools to measure their progress and achieve goals. The campaign offers free webinars, best-practice guidelines and additional resources to help staff feel more satisfied with their work and provide better care to residents.

Data collected over the course of the campaign shows that nursing homes can make significant strides in improving quality outcomes: They've decreased the use of physical restraints, improved pain treatment and shown a reduction in the development of pressure ulcers. Those are all indicators of a higher standard of care. They're often found in facilities with low staff turnover and homes that rely on consistent assignment.

For example, a decrease in the use of physical restraints might be related to a caregiver who has come to recognize the causes of agitation in a resident. For example, people with Alzheimer's disease can become agitated when they are in pain or can't ask for something they need. A regular caregiver knows what to do to calm an upset resident quickly, get them back on schedule—and prevent a situation that might otherwise be handled with physical restraints.

Nursing home residents always rate relationships with caregivers as extremely important to them. Therefore, nursing homes that adopt consistent assignments often gain a competitive edge in a tough market—one that's filled with other options.

Consumers today have choices when they need long-term care. Many go to assisted-living facilities or will comparison-shop before they pick a nursing facility. The CMS collects data on nursing home outcome measures, and increasingly consumers will check the publicly available ratings before choosing a facility.

Nursing homes that begin using consistent assignment might have to change the way they manage staffers, but after the initial startup, they often find the new way is a better way: They often catch medical problems in the early, treatable stages.

For example, a nurse who is assigned to Mrs. Jones might notice a slightly pink patch of skin, the first sign of a developing bedsore. That nurse could immediately begin treatment to prevent the skin from breaking down. If that proactive approach works, the nursing home can end up with a better bottom line because once a bedsore forms and becomes advanced, it can cost $19,000 to treat. In many cases, not all of that expense can be passed on, and the extra cost ends up hurting the facility's bottom line.

Nursing homes that rely on short-term employees or temporary staffing might not invest in competitive salaries, benefits and other factors that keep staff satisfied and on the job for the long run. The turnover rate for many nursing homes exceeds 50% per year. In contrast, some nursing homes have made changes that keep turnover rates in the single digits. High turnover can lead to demoralized employees, and in many cases, quality problems.

For example, if Mrs. Jones saw a string of different aides every day, they might not know her history, her medication requirements, her health risks, her name or what she enjoys.

Higher turnover means higher costs for finding and training new aides and nurses—replacing a single aide can cost $3,000.

The revolving door of staffers also leads to low job satisfaction for the workers left behind. But the real cost of this poor management style is a human one: nursing-home residents such as Mrs. Jones can't develop a bond with the temporary worker of the day. The temp might not know Mrs. Jones at all and will probably dismiss her refusal to enjoy her cup of coffee as nothing significant.

In the end, nursing homes that adopt consistent assignment reduce staff turnover, and that works to improve other quality measures and to help obtain something priceless: They'll have a facility that fosters strong relationships between caregivers and residents, and offers the highest standard of care.

Mary Jane Koren, M.D.

ChairAdvancing Excellence in America's Nursing Homes CampaignVice presidentCommonwealth FundNew York