Nursing-home care moves into era of professionalism. States push higher education standard for administrators

The American nursing-home industry is in the middle of a major effort to upgrade itself. At stake are public confidence, patient care, and the ability of nursing homes and their administrators to function effectively in an increasingly complex society. Also at stake, for the future, is money - lots of it. ``I've seen the evolution, from a mom-and-pop organization to an industry,'' Fred Lane says. Now ``we're in the process of becoming a profession, and that's a very difficult switch.''

Mr. Lane owns two nursing homes in Florida and is the immediate past president of the National Association of Boards of Examiners of Nursing Home Administrators. The NAB, as it's generally called, is in the forefront of the move to raise the standards for nursing home administrators, and thereby their quality.

Since 1972, the federal government has required that nursing-home administrators be licensed by their states. The NAB gives tests to would-be nursing-home administrators and certifies those who pass. According to the NAB, its certifications are used by every state except Texas to decide whether to license individual administrators.

After a year-long study, the NAB has just revised its test to make sure it reflects the work administrators do: supervise patient care and their staff, perform community-relations work, and handle finances.

The NAB is also among those forces seeking to raise the minimum education requirements for administrators. More and more states require would-be administrators to have a bachelor's degree. But eight states still require only a high school diploma, 13 ask only an associate's degree from a two-year college, and one state requires just two years of college experience.

``The first people to tell you that they want higher education [credentials] are relatives of the patients'' who are interested in highest quality of care, says Joan B. Treacy, a registered nurse who is a nursing consultant for the state of Washington's Department of Social and Health Services. She is among those who sought in vain to have Washington's minimum requirement raised to a bachelor's degree.

``The nursing-home administrators,'' Ms. Treacy says, ``have to supervise a staff that is better educated than they are'' - nurses with master's degrees, for instance. (She has a master's degree.)

Concern over the credentials of nursing-home administrators stems ultimately from concern about the quality of care that patients receive. Specialists generally agree that care is significantly better in nursing homes now than it was in the late 1960s and early '70s, when nursing-home scandals were unfortunately widespread. Yet patient care ``remains a major issue,'' says Dr. Judy Feder of the Center for Health Policy Studies at Georgetown University. Last May the Senate Aging Committee reported that many US nursing homes violate one or more of the federal government's 24 basic health, safety, or sanitary standards. ``Tens of thousands of patients in nursing homes,'' the committee said, ``still suffer from poor nutrition, inadequate nursing care, and squalid conditions thought to have been corrected long ago ... .''

Federal officials and nursing-home administrators protest that, except for a few nursing homes, this picture is inaccurate. The report was based, they say, on data that are out of date, or that rate nursing homes on their paper work, rather than their care of patients.

Four months ago the federal government changed the criteria by which it rates hospitals, which ultimately should affect the way nursing homes are judged. The most important basis for rating them will be the way they care for patients. In any case, the public perception remains what it has long been, ``that nursing homes are terrible places,'' says Marion Ein Lewin, a health-care specialist at the American Enterprise Institute. Thus many Americans, as she notes, are seeking alternatives.

The private insurance industry is beginning to write contracts to pay for nursing-home care: 1.7 percent of nursing-home expenses are paid through private insurance. But the public, in large part because of its negative perception of nursing-home care, is pressuring for private or government-backed insurance to be provided for home care, Dr. Lewin says.

Demographers say that the number of older Americans will increase dramatically in the next 35 years. Health-care specialists anticipate that enormous amounts of money will be spent to provide for the elderly. How much will flow to nursing homes will depend on their success in upgrading their standards and convincing the public that they are staffed by highly proficient professionals and provide quality care.