Improving Quality of Care for Persons with Dementia in Nursing Homes – Evaluation of the National Background Check Program

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Policymakers and researchers have long expressed concerns about resident wellbeing in nursing homes because of abuse, neglect, and exploitation. Nursing home residents are particularly susceptible to abuse and neglect because of their age, as well as physical and cognitive decline. Since individuals with Alzheimer ’s disease (AD) and Alzheimer’s Disease Related-Dementias (ADRD) have poorer functional status, more severe cognitive impairment, and are heavily dependent on caregivers for their daily activities, they are more likely to face abuse and mistreatment. Over 20% of nursing homes are cited for abuse, neglect, and exploitation every year. The National Background Check Program (NBCP) is a state-level voluntary program aimed at reducing abuse, neglect, and exploitation of vulnerable residents in long-term care settings including nursing homes. As part of the program requirements for participation in NBCP, states are required to check a) abuse registries of all states in which the prospective employee lived, b) state criminal history records, c) fingerprint-based FBI records, and d) any other records in the state that may have disqualifying information. Federal legislation allows each state to obtain up to $3 million in grants to implement NBCP. Since 2010, 29 states and territories have obtained the funding to implement NBCP over different years and are in various stages of implementation. However, link between background checks and abuse/resident outcomes is not clear. There is some evidence to show that background checks may catch potential abusers before they are hired. Moreover, background checks may also deter potential abusers from applying for jobs in nursing homes. However, background checks may not catch all perpetrators of abuse and implementation of NBCP may also lead to workforce shortages. Our objective is to evaluate the effectiveness of NBCP in lowering resident abuse, neglect, and exploitation and improving patient safety outcomes in nursing homes, overall, and by AD/ADRD census. To achieve this goal, we propose an econometric analysis for three specific aims: 1) To estimate the effect of NBCP on employment of staff who are guilty of abuse, neglect, and exploitation, 2) To estimate the effect of NBCP on citations for abuse, neglect, and exploitation, overall and stratified by high vs. low AD/ADRD census, and 3) To estimate the effect of NBCP on adverse patient quality outcomes: malnutrition, dehydration, depression, falls, pressure sores, infections, and utilization on antipsychotic drugs, overall and for individuals with AD/ADRD. The study results will yield important new knowledge about the effectiveness of NBCP in lowering resident abuse, neglect, and exploitation and improving patient safety outcomes in nursing homes, overall, and for persons with AD/ADRD. Our results have the potential to affect CMS policies on states’ use of NBCP to improve outcomes for AD/ADRD population.