Holding Nursing Homes Accountable for Quality

Alumni Profile: Alice Bonner '81, Massachusetts Secretary of the Executive Office of Elder Affairs

Alice Bonner was a geriatric nurse practitioner for two decades before moving to health care leadership. As Massachusetts Secretary of the Executive Office of Elder Affairs (EOEA), she oversees a department that connects 1.2 million seniors and their families to such services as home care, case management, nutrition and exercise programs, health coaching, job opportunities, and volunteering.  She is also an associate professor at Northeastern University’s School of Nursing. From 2011 to 2013 Bonner was director of the Division of Nursing Homes for the Centers for Medicare and Medicaid Services (CMS) at the US Department of Health and Human Services. Among her accomplishments in this role, she led a national initiative to lower the use of antipsychotic drugs in nursing homes, particularly in the case of seniors with dementia. She previously was director of the bureau of Health Care Safety and Quality at the Massachusetts Department of Public Health and executive director of the Massachusetts Senior Care Foundation. She received a BA in biology from Cornell University, a BS from Columbia Nursing, an MSN from University of Massachusetts Lowell, College of Health Professions, and a PhD from University of Massachusetts Graduate School of Nursing.

Q: You’ve spent decades working with a geriatric population. Why did you choose to work with this demographic?


I first worked with senior citizens as a college student in the late 1970s. I took a job as a nursing home assistant to earn extra money. I was a French major and had no nursing experience. I saw that the nurses made major decisions involving patient care and I rarely saw doctors. I felt inspired by their leadership. Elderly residents can get sick suddenly and these nurses often played detective to identify early warnings. For example, a resident who regularly reads the newspaper after breakfast each morning goes back to bed one day. A good nurse would examine that person for subtle changes, such as lethargy or confusion, which could signify the onset of something serious like pneumonia or a urinary tract infection.


Their compassion also impressed me. They treated residents as people instead of patients. For example, they involved them in small tasks such as folding napkins, setting the tables or gardening. By the end of the summer, I changed my major to biology and wanted to become a nurse.


Q: Several studies found that senior citizens fear moving into a nursing home and losing their independence even more than death. What are your thoughts about this? What needs to be done to change the perception that nursing homes are very institutional and may not provide the highest quality care?


In the past, many nursing homes functioned as medical, institutional environments. Families or residents and researchers sometimes reported mandatory 6:00 AM wake-up calls and bored, isolated residents who particpated in few activities.  When I accepted the job as director of nursing homes for CMS, I hoped to work with our national teams in Baltimore and other states to help improve nursing home quality across the country. Overall, nursing home quality appears to have gotten better; but there are still some nursing homes that do not meet standards of geriatric care. National and state regulations exist to protect our seniors and ensure that they receive quality care.  State surveyors inspect nursing homes regularly to monitor quality and safety.They may review the care of residents with pressure ulcers or residents who report pain or depression. Survey agencies may train their inspectors to observe additional signs of an institution’s quality.  The need to ask questions. Do the residents seem happy and engaged in meaningful activities?  Are families involved in developing plans of care? We need to hold facilities accountable when they don’t meet basic standards. 


Community members also should play a role in their area nursing homes. They can work with residents to organize music performances with local school children. They can take residents on trips to the mall and have coffee with them. They can -- and should -- report suspected wrongdoing to their local department of health.


Q: Is there evidence that collaboration among health care providers creates a safer environment for nursing home patients? What should be done to encourage more collaboration?

        Effective communication between all members of the health care team results in better and safer care. Good communication allows each team member’s distinct skills to shine: nurses excel at pain management, social workers at addressing psycho-social problems, physicians at diagnostics, and nursing assistants at keeping track of residents’ subtle changes. For example, a physician shares the rationale for prescribing a particular medication with a nurse. The nurse then communicates this reason to the social worker and nursing assistants. If the resident complains about the medication’s side effects, everyone on the team has the same information and can therefore make better decisions for the resident.


Q: How has your experience as a nurse and a nurse practitioner influenced your role as a policy maker?


I remember the stories and faces of people I’ve cared for when I work with teams to write or update policy. One CMS policy requires nursing home staff to interview patients on their goals and preferences. This information is crucial when treating residents with dementia. For example, I once cared for a gentleman with diabetes and dementia who was confused and often refused his foot care. He risked amputation of one or both feet if he didn’t take regular whirlpool baths to maintain his circulation.  By spending time getting to know him and listening, I found out that he liked to play cards, so I told him that we would play a game after he took the bath. It was a pretty simple solution, but it worked.


Q: Data show that mistakes and accidents often happen when transferring frail elders from the hospital to the nursing home or the nursing home to the emergency department. Why are advanced practice registered nurses especially qualified to address this problem and provide more continuous care?


APRNs excel at paying attention to detail, which is critical to transitions. They function like relay race runners—effectively "passing the baton’" on key patient information such as medication lists to the next set of providers. Older adults often take multiple medications, so this is especially important. APRNs also shine at communicating with patients. Patients can become depressed or confused when moving from the hospital to the nursing home. NPs know the right questions to ask to ensure they get appropriate treatment.  Effective communication also enables NPs to partner with patients on their care goals. For example, if they learn a patient wants to return home in three weeks to attend his granddaughter’s wedding, they can work towards that goal with him.


Q: You were part of a team at CMS that championed lowering the use of anti-psychotic drugs among seniors with dementia. What were the challenges? The outcomes? 


Many doctors and nurses believed these drugs worked because that’s what they were taught in medical or nursing school. In reality, anti-psychotics primarily sedate patients with dementia and while patients may appear quieter, these drugs also cause side effects such as falls, and early death. Convincing prescribers that these drugs only made patients look better on a surface level was one of our major challenges.


We created coalitions in every state comprising nurses, doctors, professional associations, advocates, researchers, ombuds, government representatives, and quality improvement organizations. Geriatric experts presented nursing home medical directors with data showing the risks and lack of efficacy with these drugs. Nursing home medical directors who effectively treated patients without anti-psychotics talked to their colleagues at other institutions. CMS was clear that they expected nursing homes to be accountable for improvement in their antipsychotic prescribing rates.  Because of the coalition’s efforts, antipsychotic medication use in US nursing homes was reduced by 20 percent over two years. Today, Medicare’s Nursing Home Compare database publishes all nursing facility anti-psychotic medication use rates on its web site. Many nursing homes engaged in developing training programs and changing policies and practices. Nursing homes were part of the problem, but they were also part of the solution.