The basis for improving and reforming long-term care, part 2: clinical problem solving and evidence-based care

There are intense efforts to improve the quality of long-term care. However, it is unclear whether these efforts are based on understanding root causes of the deficits in quality. This article focuses on processes of clinical problem solving and decision making as a means to enable safe, effective, efficient, and person-centered care that reflects key principles discussed in the initial article in this series. The care delivery process is the means for applying these principles to deliver care. The techniques used in clinical decision-making and problem-solving activities are not unique to health care. Whether or not it is recognized, clinical problem-solving and decision-making activities are occurring continually in all long-term care facilities. But only some staff and practitioners do them well. There is much talk about applying "evidence-based care" in all settings, including the nursing home. However, the term is widely misunderstood and only sometimes applied properly. True evidence-based care requires combining scientific evidence with sufficiently detailed evidence about the individual patient. This article applies the discussion to identify criteria for "expertise" in long-term care. We may identify characteristics of "experts" in long-term care, regardless of discipline, as well as factors that distinguish levels of expertise. Experts have the skill and judgment to apply knowledge effectively to individual patient situations. Based on these criteria, only some of the claims to expertise in caring for, advising about, or overseeing long-term care residents and patients are warranted.