OBRA 1987: What It Is and Why Your Therapists Need To Understand It
I first began my career in long-term care (LTC) in 1989 with a small boutique contract rehab company. As my boss was grooming me for a promotion to Regional Manager, he talked a lot about “OBRA ‘87”. While I understood this represented a landmark change from what existed before, I really had no concept of what life was like prior to the arrival of OBRA ‘87. What I did know was that it was the only reason we rehab professionals had the presence we now had in LTC. Nowadays, folks don’t talk much about OBRA ‘87, and I would venture to guess that most therapists don’t even know what it is. But they should, and here is why...
As you may know, OBRA 1987 is the Omnibus Reconciliation Act of 1987. An “Omnibus Act” is a law regularly passed by Congress and is usually a catch-all act which contains many laws, clarifications of laws, pricing updates, etc. Essentially, it is a hodgepodge of legislative issues that all get clumped together in one bill. In 1987, the Omnibus bill included what has become known as the “Nursing Home Reform Act”.
The Nursing Home Reform Act (NHRA) was a culmination of a 1986 study that was conducted at the request of Congress, by the Institute of Medicine. The study revealed that residents of nursing homes were being abused, neglected, and given inadequate care.
The basic objective of the NHRA is to ensure that residents of nursing homes receive quality care that will result in their achieving their “highest practicable” physical, mental, and psychosocial well-being.
In order to secure the desired quality care in nursing homes, the Nursing Home Reform Act requires the provision of certain services for each resident. The most significant part of the act established a Residents’ Bill of Rights, and the requirement of a comprehensive care plan for each resident. Among other things, the Residents' Bill of Rights ensures that residents have the right to choose when they get up, when they go to bed, and what they eat. (Follow this link to see the full Bill of Rights). The NHRA further specified what services a nursing home must provide for residents and established standards for these services, to include: periodic assessment of each resident, nursing services, social services, pharmaceutical services, dietary services, and rehabilitation services.
While it took years to establish enforcement of the NHRA (the implementation of the NHRA actually took longer than the drafting and passing of the law), most people will agree that the Nursing Home Reform Act in OBRA 1987 contained the most significant nursing home reforms since Medicare and Medicaid began to fund nursing home care.
To monitor whether or not nursing homes were meeting the requirements of the NHRA, the law established a certification process that requires states to conduct unannounced inspection surveys, including resident interviews at regular intervals occurring at least once every 15 months. The surveys generally focus on residents’ rights, quality of care, quality of life, and the services provided to residents. Targeted surveys are also conducted as complaint investigations in response to nursing home complaints.
By the establishment of basic rights and services for residents of nursing homes, the NHRA forms the basis for present efforts to improve quality of care and the quality of life for nursing home residents.
That basic objective of ensuring that residents achieve and maintain their “highest practicable” level of being is what drives the care planning process today. Initial and ongoing assessments of each individual allow for the establishment of an individualized plan of care for each resident, which is the heart of the law. The ongoing reassessment and revision of the plan of care informs the needs for any of the services the resident may require to reach and maintain that “highest practicable” level.
So, why should your therapists care about OBRA and the NHRA?
OBRA ‘87, and more specifically the NHRA, is what required nursing homes to provide therapy services. Prior to OBRA ‘87, nursing homes were considered retirement homes as there were no therapy services regularly provided in this setting. These were places where seniors went to live out their final days, however now many nursing home residents live for years in an environment where their varying functional needs can be identified, met, and supported.
The quarterly reassessments by the MDS team are often a source of referrals to the rehab team. By understanding the requirements of the Nursing Home Reform Act in OBRA ‘87, therapists can better understand the importance of following through on the referrals, as well as the importance of conducting their own screenings in order to help patients attain and maintain their highest level of function, improve their quality of life, and assist in ensuring that residents rights’ are safeguarded - such as remaining free from physical restraints and being able to communicate.
I have heard therapists complain that they are only required to regularly screen residents for therapy because the company they work for “wants to make money”, and while some companies don’t always have residents’ best interests at heart (google “Medicare fraud” for numerous examples), many therapists may not realize that the foundation of these regular screens is related to OBRA and NHRA. It is important that your therapy partner emphasizes education in regard to your therapy team, so they understand screens should function based on medical necessity alone and that they exist to improve residents’ quality of life and allow them to remain at their current level of function for as long as possible.
For example, I may screen Mrs. Smith and discover that while she is still able to walk, her gait is deteriorating (as evidenced by her shuffling steps, forward flexed posture, and unsteadiness). I now have the opportunity to ensure she gets the necessary services (in this case physical therapy) that can help her regain strength and balance and improve her safety in independent ambulation. This opportunity to maintain her independence is not only her right, but it is my responsibility. If I miss this early decline, I may only learn of it later after she has fallen, perhaps even broken a hip, been sent to the hospital, undergone surgery and then returned to the facility - now with less chance of maintaining her independence and quality of life for a longer period of time.
Many therapists find that identifying and picking up the long-term nursing home resident is more difficult than working with and treating the short-term rehab (Part A) patient. Oftentimes, these long-term residents have multiple comorbidities, may have some cognitive issues, and have issues that are overall more difficult to address. When educating therapy teams, we help them understand that as therapists we are the only ones who will address a resident’s therapeutic functional needs. They aren’t leaving here to go down the street to an outpatient clinic to get therapy. In other words, if we aren’t identifying and treating the residents who are in need of necessary care, then we are relegating them to continue in their current state of functioning (and possibly in a declining state of functioning). If you have therapists who are having a hard time identifying and treating these long-term residents, remind them that this is the very reason that therapists are in the nursing home space. Yes, we treat short-term residents as well, but our charge, based on OBRA ‘87 and the NHRA, is to help the residents of the facility achieve and maintain their “highest practicable" quality of life.
It is important for your clinical staff to be educated about the Nursing Home Reform Act and OBRA ‘87 so they fully comprehend how it impacts residents’ rights, their quality of life, and the maintenance of function. With this knowledge, therapists can better understand their role in delivering quality care and screens in nursing homes.
Written by: Elizabeth Johnson, PT, CDP, RAC-CT
