What's in a name? Everything.

People who receive care in nursing homes are called many things - and that's a problem

There is no core of accepted definitions for nursing home care and no set of labels to describe its recipients. As a result, I contend, the delivery of nursing home care and services, no matter at what acuity level, appears to be based on how the providers of that care identify the recipient.

My argument assumes that all relationships between nursing home caregivers and care recipients are based on the service providers' perceptions of the outcomes that the recipient is supposed to achieve. Each provider's label for the care recipient thus defines the provider's overall interaction with the caregiver in a nursing home. It appears to be a "Catch-22": Care expectations evolve from those who define the recipient, and recipients, in turn, define the care that they are to be given by their actions (or lack of same).

With this as my hypothesis, I made a class assignment to the students in my graduate social work course on aging and long-term care at the University of Connecticut. ! challenged them to research the labels currently in use to describe nursing home dwellers (i.e., those who reside in a nursing home for 24 hours or longer) by those who serve them. The students looked for the most common labels for nursing home care recipients that are used in provider directives, published policies and advertisements. The students also identified the labels used through provider interviews.

Then, as a group, the students debated the implied "recipient value" of the label (i.e., what did the label that the provider used imply about what that provider would judge to be a successful outcome for the recipient of the care?). Here is what the students determined:

* that the postal system defines nursing home care recipients as occupants (named or unnamed), whose value lies in receiving mail successfully;

* that managed care organizations (MCOs) refer to nursing home care recipients as consumers, whose value lies in their ability and willingness to purchase MCO goods and services; they are also covered lives, because managed care operates in an insurance context;

* that health maintenance organizations (HMOs) refer to nursing home care recipients as members, whose value lies in their ability to join the organization, and as customers, whose value lies in providing successful satisfaction surveys;

* that the Health Care Financing Administration (HCFA), under its Medicare and Medicaid programs, refers to nursing home care recipients as beneficiaries and recipients, whose value lies in their ability to qualify for the benefits offered under each program;

* that the Omnibus Budget Reconciliation Act (OBRA) refers to nursing home care recipients as residents, whose value lies in their right to self direction and protection from adverse practices;

* that the Joint Commission on Accreditation of Health Care Organizations (JCAHO) also refers to nursing home care recipients as residents, in deference to OBRA regulations, but also as patients, under their subacute protocol. Their value lies in the ability and mandate of a nursing home to treat a care recipient humanely and with successful clinical outcomes;

* that physicians refer to nursing home care recipients as patients, whose value lies in their ability to be successfully treated;

* that nurses define nursing home care recipients as charges, whose value lies in their ability to be successfully cared for;

* that therapists label nursing home care recipients as clients, whose value lies in their ability to "partner" in and benefit from successful therapeutic interventions;

* that admissions directors refer to prospective nursing home care recipients as applicants, whose value lies in their ability to be admitted to the facility;

* that families and other support systems (based on interviews) refer to the nursing home care recipients by any of the above labels, based on the recipient's need at the time of labeling (e.g., if a family is seeking protection of a nursing home care recipient's rights, the recipient is referred to as a "resident,"; if HMO services are being sought, as a "member");

* and that nursing home owners define nursing home care recipients as occupied beds and by payer class (i.e., Medicare, Medicaid, private-pay, etc.), whose value is as revenue sources and profit centers.

The students did not assert that any of the labeling was meant to be disrespectful or that it would adversely affect the nursing home care recipient. What was clear, however, was that they believed that the labeling limited the care and services available to the recipient based on the provider's perception. The students felt that each category of provider was essentially concerned with achieving its own outcomes, based on its own perception, to the exclusion of those of other providers. As a result, providers tended to be insensitive to the needs or limitations of other providers and therefore to the recipient as a total person.

The study was not empirical or scientific. It was a social query that attempted to explore and address an important nursing home issue, that of defining the nursing home care recipient in a consensual manner. Unless service providers can agree on who care recipients are, they cannot act as a team on behalf of the recipient. They cannot achieve successful, meaningful outcomes for the recipient because the provider, not the recipient, defines the success of the outcomes.

For instance, perhaps a nursing home care recipient does well in therapy because a therapist is aggressive or because a relationship between the therapist and the "client" has been established. The client, however, may not do as well in working with other clinical disciplines such as nurses or aides. The client's therapeutic gains may be undone in the nursing unit because its "charge" refuses to get out of bed for activities-of-daily-living (ADL) exercises.

With the implementation of Medicare's new Prospective Payment System (PPS), a new dilemma is developing. A nursing home care recipient who is a Medicare beneficiary now receives another label: a RUG (Resource Utilization Group) level of care. This means that daily reimbursement values will be assigned to the nursing home care recipient based on the recipient's functional status and ability to improve. The more dependent and therapeutically needy a recipient, the higher the RUG reimbursement available for care and services.

What is frustrating - and ironic - for nursing home care providers and recipients is that the PPS system is regulated by HCFA, the same federal bureaucracy that regulates OBRA. HCFA must, in essence, oversee and implement regulations which mandate the labeling and treatment of nursing home care recipients under two simultaneous yet mutually exclusive statuses: self-directed residents, who cannot be made to conform to RUG category care mandates, and patients at a particular RUG level, who must comply with RUG mandates to receive benefit coverage.

RUGs allow a nursing home care recipient to be classified in two ways: on ADL and therapy needs, as well as on the progress made in overcoming dependence on clinical staff. The care recipient will either progress through RUG levels of care or become ineligible for Medicare skilled nursing home benefits. Thus, it all depends on whether a nursing home dweller is feeling like a motivated RUG-level patient or like an unmotivated (for whatever reason) resident as to whether the rest of the team (including all providers of care and services) are allowed to proceed.

In conclusion, the labeling of nursing home care recipients by a variety of providers and healthcare interests creates serious dilemmas and serves no one. We may ask, "What's in a name?" The answer is, "Everything." The label indicates the direction their health care takes and how quickly services will be offered to them. Labels form the basis for admitting, treating and discharging nursing home care recipients from care and placement.

My students appear justified in their conclusion: How providers identify nursing home care recipients leads directly to how successfully they are treated.

Howard W. Dickstein, PhD, is owner of two subacute care facilities, Crestfield Rehabilitation Center and Fenwood Manor, both In Connecticut. His previous contribution to Nursing Homes/Long Term Care Management was "HCFA vs. HMO, or Welcome to the Twilight Zone," April 1998.