Improving the quality of long-term care.

Quality of long-term care can be improved by changing the strategies used to monitor it. Nursing home care has been the subject of intensive regulations, while it has been neglected by physicians. Newer forms of long-term care are coming under stricter oversight, which may stifle the innovations they offer. Greater but different attention is needed: more creativity can be fostered with better accountability by emphasizing long-term care outcomes. It is unrealistic to require that long-term care patients will improve; good outcomes are defined as doing as well as or better than expected. The Minimum Data Set for nursing homes offers a mechanism to generate data on many pertinent outcomes. An outcomes focus would encourage more collective action by the various parties involved in providing long-term care, including physicians. Clinicians are reluctant to assume responsibility for outcomes they feel unable to strongly influence, but they must recognize that part of their role is to engender cooperation from the myriad participants in long-term care, including patients and their families. Better-quality long-term care may cost more, but it may be possible to use less expensive personnel more creatively if current regulations are modified. Managed care arrangements offer one vehicle for reorganizing care and could provide the appropriate incentives to make positive changes. However, they could also lead to minimalist strategies. Accountability for realistic outcomes can provide the needed countervailing regulatory pressure.