Urinary incontinence post-OBRA: the growing challenge.

Despite many uncertainties, the pressure is on to improve management

The cost of caring for urinary incontinence continues to escalate, reflecting a burgeoning frail nursing home population. A standardized comprehensive assessment of all nursing home residents, as mandated under OBRA '87, should ensure the detection and appropriate treatment of all residents suffering from this. Whether this will in fact enhance quality of life, reduce costs and/or improve staff recruitment remains to be seen. Nevertheless, the combined challenge of growing need and increased regulatory pressure cannot be avoided.

Total costs of urinary incontinence vary from one facility to the next, since calculations are based on a number of variables, including expenses for diagnosis and evaluation, treatments employed (surgery, behavioral, medical), intensity of nursing effort, and supplies purchased, as well as indirect costs resulting from infections, skin ulcers and falls. However, and not surprisingly, nursing homes comprise the largest single segment of the incontinence product market, accounting for 36% of all purchases in 1990.(1)

The adverse effects of urinary incontinence are physical and psychosocial, as well as financial. Physical effects include skin rash and breakdown; falls; and infection of both urine and integument. Although not always causally linked, these events and urinary incontinence are consistently related. It is a certainty, as least anecdotally, that the successful treatment of urinary incontinence results in a significant decline in adverse events such as these.

The use of urethral catheters, which ranges from 5-10% in U.S. nursing homes,(2) adds yet another dimension of physical complexity, as catheters are associated with a high incidence of infection and local urethral damage.

As for psychosocial effects, although these are more difficult to measure, these impact upon both residents and staff and deter significantly from quality of life in the nursing home. Even though many incontinent nursing home residents are cognitively impaired, incontinence may still result in personal embarrassment and, at times, self-imposed isolation. Depression is not uncommon in these residents, and this may lead to further declines in overall health. Indeed, some incontinent nursing home residents may experience yet an additional loss of control, resulting in continually increasing dependence and decreasing self-esteem.(3)

Another not-often-discussed psychosocial cost of urinary incontinence is its impact on nursing home staffing. Care of incontinent nursing home residents is demanding and engenders a number of feelings and behaviors among nursing home staff that are potentially deleterious to good care. For some, negative feelings may be displaced directly to the incontinent resident being cared for and result in a worsening situation. For other staff, negative feelings are subdued and substituted by "over-indulgence, ultra-permissiveness and excessive caring."(3)

Up to one-half of nurses and nurses aides may admit to feeling irritable toward incontinent residents, as well as feeling discouraged and frustrated. Urinary incontinence is often cited as the reason for leaving nursing home employment.(3)

The Growing Concern

Exemplary of problems relating to medical care in the nursing home, and germane to the issue of urinary incontinence, are two studies which measured how frequently urinary incontinence was recorded as a medical problem in the days before OBRA '87. According to Ouslander(4) and Ribeiro,(5) urinary incontinence was identified as a problem in less than 15% of all residents actually afflicted with the condition.

The now-famous Institute of Medicine Report, "Improving Quality of Care in Nursing Homes," concluded that more effective government regulation was the key to improving quality in nursing homes.(6) The majority of the IOM recommendations were, of course, incorporated into the Nursing Home Reform package and passed Congress as part of the Omnibus Reconciliation Act (OBRA) of 1987. This new Act represented the most substantial change in both standards and the regulatory process since Federal funding and regulation of nursing homes began some 20 years earlier.

Meanwhile, the nursing home population itself has undergone a relatively rapid transformation. Over the past decade, many elderly patients have been discharged from acute care hospitals "quicker but sicker," due to Medicare's prospective payment system. This increasing complexity of care needs, post-DRGs, has placed an additional burden on nursing homes already faced with intensive governmental oversight. Medical care of these residents is further complicated by the need to employ a large paraprofessional work force and by the general lack of interest and involvement in nursing home care evidenced by many physicians.

Recent developments have given cause for hope on this score, however. Under the new regulations, and in light of the increasing complexity of medical care in the nursing home, physicians are expected to take a much more active role in the management of their nursing home residents than has traditionally been the case. Physicians must participate actively in the development of individual care plans and review and revise such plans periodically with the help of the health care team. The physician is responsible for implementing specific treatments and/or services striving to enhance and/or maintain physical and psychosocial function whenever possible. Needless to say, urinary incontinence will be the focus of much of this.

Today's Assessment Tools

The Resident Assessment Instrument is currently in use as either the minimum dataset (MDS) or MDS (+). Specific responses in 18 domains, including urinary incontinence, will trigger more extensive evaluation, as outlined by specific guidelines embodied in the Resident Assessment Protocols (RAPs). The trigger item suggests that a problem already exists or likely to develop unless preventive measures are taken.

Thus, if urinary incontinence is present on a recurring basis, or if catheters or pads are being utilized, then a series of questions are posed which highlight potentially reversible causes of the incontinence. The rationale, again, is to ensure that each resident's problems are identified in the most expeditious fashion possible and treated appropriately.

Mixed Implications

In theory, at least, the new Resident Assessment Instrument and Assessment Protocols are a significant step forward toward the comprehensive evaluation and treatment of all nursing home residents within an interdisciplinary context. Of prime concern to nursing homes, however, has been the possible cost of implementing the new OBRA reforms. Although estimates range from $3-8 per day of added expense per nursing home resident, it is not as yet certain whether these costs will be recovered.

Unanswered questions also relate to the care planning process itself. Will the new Assessment Protocols paradoxically curtail flexibility in care planning and impede creativity? Although the Resident Assessment Protocols are offered as guidelines, how will surveyors, in fact, interpret deviations from Protocols? How much documentation will actually be enough to satisfy the regulators that deviation is, in fact, warranted? Inconsistencies between survey teams (state to state and even between adjacent counties) continue to plague the system. Problems will remain until all surveyors, regardless of location, are subjected to the same rigorous quality assurance standards applied to each and every nursing home in the United States.

Another concern for nursing home administration is, how will the physician fare under this new system? Will physicians feel more and more alienated from the care planning process, erroneously believing that the Resident Assessment Protocols and other regulations leave little room for independent decision making? Will the increased oversight combined with still inadequate remuneration drive more and more physicians away from the nursing home?

Despite all the uncertainties, it is clear that nursing home staff must do all that it can to realize OBRA '87's potential in upgrading management of urinary incontinence. This is one of the clinical yardsticks by which all nursing homes will be measured in the 1990s, not only by regulators, but by residents and their families. More can, and should, be done.

References

1. McKnight's Long Term Care News 1991; 12(5):1.

2. Warren JW. Catheters and catheter care. In Ouslander JG (ed), Urinary Incontinence. Clinics in Geriatric Medicine 1986; 2:857-871.

3. Ory MG, Wyman JF, Yu LC. Psychosocial factors in urinary incontinence. In Ouslander JG (ed), Urinary Incontinence. Clinics in Geriatric Medicine 1986; 2:657-671.

4. Ouslander JG, Kane R1, Abrass IB. Urinary incontinence in elderly nursing home patients. JAMA 1982; 248:1194-1198.

5. Ribeiro BJ, Smith SR. Evaluation of urinary catheterization and urinary incontinence in a general nursing home population. J Am Geriatr Soc 1985; 33:479-481. 6. Institute of Medicine, Committee on Nursing Home Regulation Improving Quality of Care in Nursing Homes. Washington, D.C.: National Academy Press, 1986.

Paul R. Katz, MD is Director of Long-Term Care, Veterans Administration Medical Center, Buffalo, NY.