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At this meeting, services to be provided and general contractual arrangements can be discussed. Points of discussion should include who will be the administrative contact person(s) within the nursing home, how scheduling will be accomplished, what space is available for examinations, legal responsibilities of the provider (See IV. C. Governmental Regulations), and ophthalmic policy. The types of contractual arrangements can vary widely, from loosely patterned to more formal agreements requiring the services of an attorney. Once an agreement to proceed is reached, a second meeting should be arranged to meet with other staff within the facility (e.g., the Medical Director, Director of Nursing, and Director of Social Services). Once the nursing home vision program is started, it is wise to periodically review the agreement with the nursing home and to meet with these key staff to discuss problems. The advent of managed care has brought increases in the number of health care systems providing a continuum of services. In these systems, a single entity may be involved in ambulatory care, inpatient hospital services, home care, and long-term nursing care. In many instances, these systems revolve around the hospital as a focal point. Optometrists who are not members of the hospital staff may find it difficult to obtain privileges to see nursing home residents. Conversely, seeking privileges to see nursing home residents may be a valuable entree into the hospital and ambulatory care network. Due to the unstable health status of many nursing home residents, hospital admissions with discharge back to the nursing home are not uncommon. These frequent admissions and discharges can make continuing care difficult. The optometrist should be alert to the fact that each new admission to the nursing home may result in a new chart being started. It is possible that during the course of multiple admissions and discharges that ophthalmic medications may be left off of physicians' orders. Obtaining privileges that allow optometrists to evaluate nursing home residents while in the hospital can alleviate this problem.
Nursing facilities are regulated by the federal government through rules and operating standards established by the Health Care Financing Administration (HCFA). In response to reports of widespread neglect and abuse in nursing homes, the Congress, in 1987, enacted legislation to reform nursing home regulations and require nursing homes participating in the Medicare and Medicaid programs to comply with certain requirements. This legislation, included in the Omnibus Budget Reconciliation Act of 1987 (OBRA 1987), also known as the Nursing Home Reform Act, specifies that a nursing home "must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care..." These rules and operating standards were established to protect the rights of the residents living in nursing facilities and to guarantee the availability of a minimum level of services to meet their health and psychosocial needs. Nursing facilities must comply with the requirements of the federal government in order to be certified and to receive payment under the Medicare and Medicaid entitlement programs.
A standard survey of nursing facilities, performed on a yearly basis, assures the public that the Life Safety Code Requirements and Resident Care Requirements are being met. The survey is a resident-centered, outcome-oriented inspection and assesses the following areas:
o The facility's compliance with residents' rights
The accuracy of the residents' comprehensive assessments and the adequacy of care plans based on these assessments
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