Research in long-term care: issues, dilemmas, and challenges from the public purchaser's perspective

Expenditures for long-term care for older Americans are sizable and likely to increase as the population ages. As the largest purchaser of health care for this group of citizens, the Centers for Medicare & Medicaid Services (CMS) is working to improve the quality of the long-term care services it purchases through quality monitoring and enforcement, providing information to beneficiaries about quality of care and enhancing resources to improve quality. Although CMS has used the best scientific information available to inform the planning of quality initiative projects, there are a number of issues, dilemmas, and challenges for which the research base is insufficient to fully answer programmatic needs. In many instances, research needs in the long-term care setting differ substantially from those in acute care. Using the Nursing Home Quality Initiative as an example, this article presents a descriptive, conceptual discussion of strategic issues and a summary of research that would be valuable in informing critical areas of decision-making in quality and outcomes research over the next decade. The issues, dilemmas, and challenges discussed are grouped into 5 categories: measurement methods and tools, uses of quality data, organizational and cultural factors, information and informatics, and impact evaluation and research.