The Jewish Center for Aged, a 275-bed long-term care facility in Chesterfield, Mo., established a restorative nursing program intended to enhance the safety and comfort of residents.

Key Results: The Jewish Center for Aged developed four divisions of the program.

• Positioning Division. Develop individualized procedures whereby nursing staff can easily and consistently follow through on residents' positioning needs to prevent contractures (deformities or distortions caused by permanent shortening of muscle or scar tissue); minimize pain, stiffness and edema; facilitate independent self-care; increase socialization; and maximize skin integrity and ability to interact with the environment.
• Exercise Group Division. Improve residents' ability to perform active, resistive exercise for strength, flexibility and activity tolerance; enhance functional mobility and ability to perform activities of daily living; increase socialization; and allow restorative aides more time to work with residents to complete other modalities.
• ADL Enhancement Division (called the "Walk to Dine Program"). Facilitate independence in eating in a small group environment and improve mealtime behavior, self-image, and socialization skills through the use of individualized goals.
• Skin Integrity Division. Identify residents at risk for skin breakdown, falls and poor sitting posture, and provide such residents with mechanical supports and positioning techniques and/or devices.

The Problem: In 1987, Congress passed the Nursing Home Reform Act, as part of the Omnibus Reconciliation Act (OBRA), to improve the quality of care in nursing homes.

Rehabilitation and restorative nursing services, which promote nursing home residents' ability to live as independently and safely as possible in their environments, are integral components of the services mandated by OBRA.

Skilled therapists (physical, occupational and speech) develop individual programs for nursing home residents and train restorative nursing assistants to deliver them.

Then, as a result of the 1997 Balanced Budget Act, Medicare funding for rehabilitative services in long-term care facilities was cut and capped at $3,000 per resident annually ($1,500 for occupational therapy and a combined $1,500 for physical and speech therapy).

While the caps have been suspended since late 2000 while the Health Care Finance Administration (now the Centers for Medicare & Medicaid Services) studies possible modifications, the Balanced Budget Act has had the effect of directing long-term care facilities' restorative nursing resources toward preventive services which are not capped, preserving therapy caps for catastrophic needs.