By Barbara J. Zarowitz, PharmD, BCPS, BCGP, FCCP, FASCP

This guest blog is part one in a two-part series on quality improvement in long-term care. To read part two, click here.

The quality of care in long-term care facilities can be described rather like United States Supreme Court Justice Potter Stewart defined “obscenity” in a 1964 court case of Jacobellis vs. Ohio:

“I shall not today attempt further to define the kinds of material I understand to be embraced within that shorthand description…But I know it when I see it.”1Quality is a value you recognize when you see it yet it is difficult to measure meaningfully in long-term care (LTC).

Despite substantial improvements in nursing home quality, the quality of care delivered to long-term care residents remains inconsistent. Nearly 25% of nursing homes have serious deficiencies that cause actual harm to residents or place them at risk of death or serious harm.2Some key quality gaps are the rate of re-hospitalization in the 30 days following hospitalization, use of physical and chemical restraints, pain management, falls and fractures, unintended weight loss, untreated depression, adverse drug events, and antimicrobial prescribing practices.3-6  Efforts to improve quality are frequently thwarted by barriers due to the complexity of care in older adults and an insufficient number of clinical staff trained in managing geriatric syndromes and multimorbidity, such as behavioral symptoms in patients with dementia. 

Surveyor-reported nursing home deficiencies have identified an estimated mean of 1.5 falls per nursing facility bed per year, with 4% resulting in fracture and 11% resulting in serious injuries such as lacerations and head trauma. Another systematic review of 66 studies of medication safety in nursing homes reported that the incidence rates of adverse drug events in nursing homes ranged from 1.89 to 10.8 per 100 resident-months.6 The most common adverse drug events were bleeding, thromboembolic events, hypoglycemia, falls and constipation, only some of which are captured in current quality measures.10  These types of persistent quality problems, with regard to medication management, result in adverse medication consequences.8-10

How do healthcare providers and nursing homes work together to improve performance and the quality of clinical care for older adults? In Ontario, the Ministry of Health and Long-Term Care (MOHLTC) has funded a program that’s well underway (with the Ontario Long Term Care Association and AdvantAge Ontario as program partners). The program brings evidence-based clinical knowledge and best practice to long-term care homes across Ontario, in the form of Clinical Support Tools (CSTs). These condition-specific CSTs, some of which include Palliative and End-of-Life, Hypoglycemia, Urinary Continence and Behavioural Symptoms of Dementia, enable clinicians to provide individualized and holistic care for residents. As the service provider of these tools, Think Research, along with the program partners, has already begun to transform long-term care by creating greater visibility on clinical quality, bringing resident and provider satisfaction to the forefront, and basing patient care decisions on the best scientific evidence available. 

Nursing home quality does not have to remain elusive, so we “know it only when we see it.” Quality can be defined, expected, measured and made public with transparency. In addition to setting expectations and holding health care providers accountable, technology and evidence-based clinical support tools, such as those designed by Think Research, are significant assets for achieving quality clinical outcomes.

Specializing in Geriatric Pharmacotherapy and Clinical Research, Barbara J. Zarowitz, Pharm. D, is the Senior Advisor at The Peter Lamy Center on Drug Therapy and Aging at the University of Maryland’s College of Pharmacy, and an Independent Consultant in Las Vegas, Nevada. Stay tuned for part two of Barbara’s blog series on quality improvement in long-term care.

  1. Peter Lattman (September 27, 2007). “The Origins of Justice Stewart’s ‘I Know It When I See It'”Wall Street Journal. LawBlog at The Wall Street Journal Online. Retrieved December 31, 2014.
  2. Wiener JM. An assessment of strategies for improving quality of care in nursing homes. The Gerontol 2003;43:19-27, available at:
  3. Morley JE. The future of long-term care. JAMDA 2017;18:1-7, available at:,11.001
  • Simmons SF, Schnelle JF, Sathe NA, et al. Defining safety in the nursing home setting: implications for future research. JAMDA 2016;17:473-81, available at: http://dx/
  • Thompson ND, LaPlace L, Epstein L, et al. Prevalence of antimicrobial use and opportunities to improve prescribing practices in U.S. nursing homes. JAMDA 2016:17:1151-3, available at:
  • Rubenstein IZ, Josephson KR, Robbins AS. Falls in the nursing home. Ann Intern Med 1994;121:442-51.
  • Rochon PA, Gurwitz JH. Prescribing for seniors: neither too much nor too little. JAMA 1999;2832:113-5.
  • Steinman MA, Landefeld CS, Rosenthal GE, et al. Polypharmacy and prescribing quality in older people. J Am Geriatr Soc 2006;54:1516-23.
  • Handler SM, Wright RM, Ruby CM, et al. Epidemiology of medication-related adverse events in nursing homes. Am J Geriatr Pharmacother 2006;4:264-72.