Quality of Care and Health Care Standards Research


Quality of Care and Health Care Standards

Program Director: John N. Morris, Ph.D.
Elizabeth Howard, Ph.D.

Program Importance and Goals
Maximizing quality of life and functional independence, as well as reducing distressful symptoms of physical and mental-health conditions, remain some of the greatest health-care challenges in the United States and around the world.

Seniors are cared for in a wide variety of residential settings and health-care programs, and the disparity of outcomes across these settings is enormous. The focus of this program has been to devise ways to reduce such disparity and help clarify how best outcomes can be obtained, no matter the setting.

IFAR researchers have studied senior and other vulnerable populations who receive care in nursing homes, home care, senior housing, continuing care retirement communities (CCRCs), hospice, mental health facilities, assisted living and the general community. They have examined the efficacy of specific approaches for helping seniors maximize their functional status, including:

  • the introduction of state-of-the-art care protocols such as nursing-based rehabilitation
  • innovative assessment and care strategies
  • new ways to monitor system performance
  • innovative approaches to assist elders to remain cognitively intact

IFAR researchers have developed and studied technical strategies designed to expedite the work processes in these environments, including comprehensive assessment tools, validated measures to assess the quality of the outcomes within program agencies, and strategies to empower staff to assume leadership roles in driving quality outcomes in their environments.

IFAR researchers have helped develop a suite of integrated assessment tools for use by health care and other professionals to assess patient status, focus care planning, and track care progress. Comprehensive assessment forms the structure for an integrated information technology that can target care, establish quality indicators, and set standards for payment and quality.

Program Accomplishments
Dr. John Morris's research program is one of the oldest and most successful social gerontology research programs in this country, committed to improving the quality of life and care of older adults.

It conducted one of the first studies to demonstrate the role of supportive housing as an alternative to nursing homes for impaired elders. This research led to Hebrew SeniorLife's decision in the 1970s to build congregate housing, rather than add more nursing home beds.

With Brown University, the program conducted pioneering work demonstrating the value of hospice care for terminally ill patients. It also played the lead role under several government contracts to design and implement a new method called the Resident Assessment Instrument - Minimum Data Set (RAI-MDS) to assess the abilities and needs of residents in nursing homes, and use the information obtained to determine the quality of nursing home care.

As a result of this work, similar assessment and care planning tools have been developed in many different countries. Dr. Morris assumed a leadership role in the development of an international group of like-minded researchers known as interRAI. Their efforts have opened up research opportunities in Canada and elsewhere, facilitating IFAR's access to unique research-quality international data sets for persons in nursing homes, home care, and other care settings.

The Quality of Care and Health-Care Standards Program also has a well-established track record of conducting randomized controlled trials in nursing homes and the community, beginning with studies that showed how exercise and nursing rehabilitation interventions can prevent functional decline in nursing home residents.

One of the most successful community-based randomized trials is the ACTIVE study, a six-site NIH-funded trial that showed how mental exercises can help elders maintain their memory and reasoning abilities.

Dr. Morris recently began a new initiative called COLLAGE, which is a national consortium of CCRCs under IFAR and Kendal Corporation sponsorship. COLLAGE envisions a minimum enrollment of 100 CCRCs from around the country, and once further established, COLLAGE will provide a valuable database to study factors that promote healthy aging.

Program Impact
Under the direction of Dr. Morris, this program has made important contributions to the long-term care of seniors at HSL and internationally in three major areas, including the development of methods to assess the functional abilities and needs of seniors, the establishment of best-care practices in a variety of patient care settings, and the measurement of quality of care in these settings.

The program has helped set the highest standard of care for nursing homes across this country by developing the RAI-MDS resident assessment system that is now required by law to be used in all Medicare or Medicaid-supported nursing facilities in the US.

This system has been adopted by 24 other countries and has been adapted for use in numerous other settings that provide acute, post-acute, mental health, and home care. Under a contract from the Center for Medicare and Medicaid Services (CMS), Dr. Morris has used this system to derive quality indicators that inform patients, families and regulators about the quality of care provided in nursing homes, and thus set the standards of care that all must achieve.

This program has a long history of disseminating its research findings in the United States and around the world. Senior staff founded:

  • a company called LTCQ to help bring a science-based approach to care to US nursing homes;
  • an international organization called interRAI to bring new approaches to assessment, care planning, and quality measurement to the acute- and long-term arena around the world;
  • HURI, a collaboration with the University of Michigan that provides health policy research and consultation for state governments throughout the US.

At Hebrew SeniorLife, Dr. Morris and colleagues introduced the MDS, taught staff how to perform its resident assessments, and provided measures and data that enabled HSL to compare its quality to that of other nursing facilities.

Dr. Morris's program has also served HSL directly by conducting several rounds of the Employee Morale Survey, completing a relocation survey after renovation of the Berger Building, developing an intake functional risk-avoidance model for Orchard Cove, and completing acuity surveys to help support our requested Medicaid rate.

At the current time, Dr. Morris and several other members of this group are working with staff from Nursing, Medicine, IT, and elsewhere at HSL to develop and implement an innovative program to ensure that resident outcomes at Hebrew Rehabilitation Center are among the very best in the country. The goal, once the effectiveness of the program is demonstrated, is to place HSL in the position of being able to lead the national debate on what is possible, from a quality standpoint, in American nursing homes.

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