ABSTRACT
The lack of a systematic and comprehensive pain manage-
ment program is a common quality problem in nursing
homes. The purpose of this article is to address the business
case for effective pain management in this setting, includ-
ing the conceptual domains and processes that should be
considered in improving quality and reducing costs. Unfor-
Debra Bakerjian, PhD, RN, FNP; Suzanne S. Prevost, PhD, RN, COI; Keela Herr, PhD, RN, AGSF, FAAN;
Kristen Swafford, MS, RN, CNS; and Mary Ersek, PhD, RN, FAAN
42
tunately, the literature contains very little to inform those
working to implement effective and efficient pain man-
agement programs in nursing homes. This article suggests
several strategies for establishing an internal business case
to support the implementation of a comprehensive pain
management program in a nursing home setting.
2012 iStockphoto.com/gst.casper
Copyright SLACK Incorporated
C oncerns about the quality of
care in nursing homes have
prompted public outcries,
grassroots advocacy movements,
and an array of mechanisms to in-
crease state and federal oversight.
The Agency for Healthcare Research
and Quality (AHRQ) and the Cen-
ters for Medicare & Medicaid Ser-
vices (CMS) are both federal agen-
cies concerned with quality of care
in nursing homes. AHRQ is charged
with ensuring that health care is of
the highest quality and is appropri-
ate and effective, while CMS is the
primary payer of services for older
adults and is concerned with the
value of the services delivered. Both
agencies have identified pain man-
agement as a quality of care issue in
nursing homes and have sponsored
several efforts to improve quality of
pain management in the past (CMS,
2010; Wells, Pasero, & McCaffery,
2008). CMS incorporates pain man-
agement into its overall quality score
in its Five-Star Quality Rating Sys-
tem (CMS, 2010).
More than 1.5 million adults re-
side in nearly 16,000 freestanding
nursing homes in the United States,
and studies report pain prevalence
rates range from 47% to 82.9%
among nursing home residents (Sha-
piro, 1996; Zanocchi et al., 2008;
Zwakhalen, Koopmans, Geels,
Berger, & Hamers, 2009). The high
prevalence of pain and its common
undertreatment in nursing homes
have been documented by clinicians
and researchers for the past 2 decades
(Bernabei et al., 1998; Teno, Bird, &
Mor, 2002; Teno, Kabumoto, Wetle,
Roy, & Mor, 2004). Pain continues
to be a common chronic condition
in nursing home residents that is of-
ten unrecognized and undertreated
(Decker, Culp, & Cacchione, 2009;
Hadjistavropoulos et al., 2007; Hutt,
Pepper, Vojir, Fink, & Jones, 2006;
Won et al., 2006).
JOURNAL OF GERONTOLOGICAL NURSING VOL. 38, NO. 2, 2012
Pain may be associated with
acute conditions such as surgery or
trauma but often arises from com-
plex chronic medical conditions. A
particular challenge is pain that oc-
curs in nursing home residents with
dementia who are unable to provide
reliable self-report. These residents
may frequently cry out with vocal-
izations that are disturbing to other
residents, as well as to staff, and have
higher risk of aggressive behaviors
that contribute to increased care-
giver burden and stress (Kunik et
al., 2010). Another hindrance is that
some residents make frequent re-
quests for pain medications and may
be labeled by staff as drug seekers. In
addition, the complexities of assess-
ing and treating pain coupled with
limited staff can bias administrators
and staff into believing that effective
pain management is labor intensive,
expensive, and exceeds available re-
sources. The fallacy in this line of
thinking is that anticipatory, preven-
tive pain management interventions
are often the most clinically effective
approachesas well as the most effi-
cient use of staff timeand are con-
sistent with high quality of care.
Although Americans continue
to be concerned with the quality of
health care, they have also developed
a heightened sensitivity to the high
cost of this care. Expenditures now
exceed $2.3 trillion per year and ac-
counted for 16.6% of the gross do-
mestic product for 2008 (Keehan et
al., 2008). The oldest old (>85) adult
population, the fastest growing seg-
ment of society (U.S. Census Bu-
reau, 1995), are known to be dispro-
portionate users of health care and
account for more than one third of
health care costs (Hartman, Catlin,
Lassman, Cylus, & Heffler, 2008).
At the same time, their quality of
care has also been under scrutiny
for the past several years (Boyd et
al., 2005; Warshaw, 2009). Nursing
home care (now more than $125 bil-
lion per year) and prescription drug
expenditures (more than $217 billion
per year) are both frequently cited
as areas of concern in relation to the
tremendous cost of caring for older
adults (The Henry J. Kaiser Fam-
ily Foundation, 2008). As geriatric
leaders are challenged to focus on
these excessive costs and to provide
high-quality care in the most frugal
manner, the temptation to sacrifice
quality in the name of cost savings
is high. Therefore, addressing the
financial aspectsboth benefits and
costsfor improved pain manage-
ment in nursing homes is an impor-
tant process for geriatric leaders to
embrace. Unfortunately, the litera-
ture contains little research on the
business case for pain management
in nursing homes. This article ad-
dresses the conceptual domains and
processes that should be considered
in improving quality and reducing
costs in a comprehensive pain man-
agement program.
PAIN MANAGEMENT IN
NURSING HOMES
Primary goals for any pain man-
agement program revolve around de-
creasing pain to an acceptable level,
maintaining or improving functional
capabilities, and enhancing quality of
life (Jablonski & Ersek, 2009). Older
adults in nursing homes are typically
not in control of this process and rely
on nursing staff to help them achieve
these goals. In many cases, nursing
staff must anticipate the needs of
older adults, particularly those with
cognitive decline. An effective and
efficient pain management program
can improve the quality of care for
nursing home residents and may
greatly enhance their quality of life
as well. Therefore, a comprehensive
pain management program must
consider quality-of-life issues such
as residents ability to have daily so-
43
Figure 1. Mechanisms to make the business case for a pain management program.
Note. ROI = return on investment.
cial interactions or to sleep through
the night.
Unmanaged or poorly managed
pain can affect other chronic condi-
tions as well. Consider the effect of
pain on diabetic residents with neu-
ropathic pain or patients with severe
arthritis who can no longer feed
themselves due to poorly managed
pain. Poorly controlled pain can
contribute to respiratory distress in
patients with congestive heart failure
or chronic obstructive pulmonary
disease. Nursing staff are responsible
for assessing nursing home residents,
ensuring effective and timely deliv-
ery of therapies, and monitoring for
pain reduction. Nursing home per-
sonnel who lack knowledge in these
areas will not be effective in decreas-
ing residents pain. Additionally, the
lack of systemized care processes
44
contributes to poor management of
pain, so leadership in nursing homes
should strive to have policies and
procedures in place that will assist
nursing staff in meeting pain man-
agement goals (Swafford, Miller,
Tsai, Herr, & Ersek, 2009).
Barriers to Effective Pain
Management
Studies have identified several
obstacles to effective pain manage-
ment in nursing homes. These can
be categorized into at least three ar-
eas. First, health care professionals
lack knowledge and clinical exper-
tise, resulting in fears of overdose
and addiction, difficulties with as-
sessing pain, and problems selecting
or accessing the preferred medica-
tions (Jones et al., 2005). Second,
insufficient education and aware-
ness on the part of older adults
in nursing homes or their family
members results in misconceptions
and concerns regarding side effects,
overdose, and addiction and may
contribute to a hesitancy to ask for
help or report pain. Dementia is a
common problem that further com-
plicates older adults ability to re-
port pain. Finally, facilities have not
used existing processes and tools
effectively to better manage pain
(Weiner & Rudy, 2002). Another
barrier that is rarely acknowledged
but could be the source of some of
these impediments, is the cost (both
real and perceived) associated with
providing high-quality pain man-
agement. Unfortunately, almost no
research has been conducted on the
cost of pain management in nursing
homes. Therefore, we must look to
Copyright SLACK Incorporated
evaluations of cost in other settings
to develop a beginning business case
for pain management.
METHODS FOR MAKING THE
PAIN MANAGEMENT BUSINESS
CASE
To establish a business case for
a comprehensive pain management
program, nursing home leaders need
to weigh the benefits (improved
quality of care and resident/family
satisfaction) and the associated costs
(training, additional staff, supplies)
of the program. Unfortunately, little
information regarding costs or bene-
fit analyses has been published in the
pain literature. However, a variety
of ways to evaluate the business case
for other quality processes have been
used; these include cost benefit and
cost effectiveness, return on invest-
ment, revenue enhancements, cost
savings, and cost avoidance (Epstein
& Peters, 2009; Luck, Parkerton, &
Hagigi, 2007; Lurie et al., 2008; Virk-
stis, Westheim, Boston-Fleischhauer,
Matsui, & Jaggi, 2009). Figure 1 pro-
vides a brief overview of these meth-
ods that are further explained in the
sections below. Each of these pro-
cesses requires estimating the costs
of the program and the benefits de-
rived from program implementation.
The business case can be made if the
benefits outweigh the costs and qual-
ity is improved or at least maintained
(Luck et al., 2007).
Cost Benefits and Cost Effectiveness
A frequently cited benefit of a
comprehensive pain management
program is increased quality of life
for individual residents that results
in improved quality measures for
nursing homes (Lurie et al., 2008). In
light of the move toward making care
more resident focused, incorporat-
ing resident experiences of care and
quality of life issues are increasingly
important when measuring improve-
ment in health care delivery services.
Research has shown that involving
patients in the decision-making pro-
cess in these areas may reduce costs
JOURNAL OF GERONTOLOGICAL NURSING VOL. 38, NO. 2, 2012
SIDEBAR
OPERATIONAL STRUCTURES AND PROCESSES IN PAIN
MANAGEMENT
Baseline evaluations of staff knowledge, current pain management interven-
tions, and patient outcomes regarding pain (i.e., incidence, prevalence, types,
severity, resident and family satisfaction), along with determination of staff
competencies
Targeted educational offerings for both licensed and unlicensed staff
Educational interventions for residents and their families related to pain
Additional staff time for more comprehensive pain assessment and documen-
tation
Modifications to documentation forms and revision of practices to meet cur-
rent standards of care for comprehensive pain management
Nonpharmacological intervention resources (e.g., heat and cold applications,
massage)
Information resources (e.g., pain texts, journals, guidelines, standards, Internet
access)
Acquisition of additional or more effective analgesic and adjuvant medica-
tions when needed
Standardized, evidence-based practices that emphasize comprehensive as-
sessment and management
Addition or designation of key personnel to lead the change (e.g., advanced
practice nurse, pain management consultant) and key staff to facilitate the
change on each unit
Designated personnel and time to monitor and audit process improvements
while improving satisfaction; thus, the projected direct (e.g., new nurs-
integrating the residents voice into ing staff, additional staff time, medi-
care may be an important part of the cations, supplies) and indirect (e.g.,
quality improvement process (Ep- management participation, increased
stein & Peters, 2009). In estimating demand for services, reinforcing
the benefits of a program, the analy- standards) costs of the program. In-
sis should include evaluating the im- terventions that show cost savings
pact of the program in terms of re- should obviously be implemented;
duced redundancy (e.g., timing and however, even if there is not a sig-
documentation of assessments, doc- nificant cost reduction, there may be
umentation in multiple places on the other reasons for implementing the
medical record), improved efficien- program. One weakness of a cost-
cies (e.g., preprinted evidence-based benefit analysis is that it does not
forms, structured communication, take into consideration that some
procedures for nonpharmacologi- programs improve quality in a way
cal treatments), and decreased costs, that cannot be captured in financial
such as avoidable hospitalizations, measures but have a substantial effect
that are currently being scrutinized on the improvement of quality of life
as a means of reduced payments to and therefore may be worth imple-
facilities. menting, even at a higher cost. This
Estimating the costs of a pain may be the case with pain manage-
management program includes the ment, so managers should consider
expected start-up costs of imple- that a cost-effectiveness analysis
menting a program (e.g., training, (CEA) may provide better support
equipment, consultants) along with for the business case.
45
 CEA is a form of economic analy-
sis that compares relative costs and
outcomes of different courses of ac-
tion (Centers for Disease Control
and Prevention, 2006). A key differ-
ence from cost-benefit analysis is that
the impact of cost effectiveness does
not have to be measured in monetary
costs and considers reduced morbid-
ity and delayed mortality in the equa-
tion and thus will typically estimate
the quality-adjusted life years instead
of estimated dollars.
A number of additional potential
benefits may be difficult to quantify
but are also important to quality of
Patient outcomes demonstrating effective pain
management could be used as a tool to market
the facility to local physicians and hospital
discharge planners.
care. Improved satisfaction in residents
and families can be an excellent mar-
keting tool and may also have more
direct financial implications if satis-
fied residents stay in the facility and
recommend the facility to others. Im-
proved satisfaction and morale of staff
are associated with improved retention
and reduced staff turnover, which may
directly reduce costs (Dupree & Lin,
2008). Use of a structured pain assess-
ment tool and process to help recog-
nize pain in individuals with dementia
has been shown to decrease staff stress
and increase morale in nursing home
nurses, which may contribute to staff
retention and decreased costs (Had-
jistavropoulos et al., 2007).
Another significant issue is that
pain management, particularly pain
assessment, is a nurse-sensitive pro-
cess. Unfortunately, nurses are almost
always viewed as a cost center with
46
the fixed charges included in the daily
room rate. Studies have shown that
including nursing costs into room and
board does not reflect the variability
in nursing care requirements, nor the
costs of providing nursing care, mak-
ing it difficult to place appropriate
value to nursing care (Unruh, Hass-
miller, & Reinhard, 2008). Few stud-
ies have examined cost savings related
to nursing care; however, those that
have show that increased RN time im-
proves outcomes and contributes to
cost savings (Aiken, Clarke, Cheung,
Sloane, & Silber, 2003; Horn, Buer-
haus, Bergstrom, & Smout, 2005). In
addition, some researchers suggest
that changes in pay for performance
and in prospective payment sys-
temswhere several nurse-sensitive
outcomes (e.g., catheter-associated
infections, pressure ulcers, glycemic
control, falls) are identifiedindicate
there may be incentives to perform
a greater analysis of nursing costs in
relation to nurse-sensitive outcomes
(Horn, 2008). One issue that may
be even more problematic in nursing
homes compared with hospitals is the
overall low numbers of RNs needed
to perform a comprehensive pain as-
sessment. The ratio of RNs to resi-
dents should be considered as part of
this analysis.
Considerations for Return on
Investment
In a time of limited resources, in-
vestments in quality improvement
require justification, particularly in
a nursing home setting. Fiscally re-
sponsible organizations invest in
quality improvement only if there
is a reasonable return on that invest-
ment (Greene et al., 2008). These in-
vestments can be viewed from three
different perspectives: (a) revenue
enhancing, (b) cost savings, and (c)
cost avoidance. Toward this end,
nursing home directors and admin-
istrators should consider the impact
of enhanced pain management on
potential revenue enhancements,
cost savings, and cost avoidance, as
well as patient and staff outcomes
and the less tangible quality-of-care
measures.
Potential Revenue Enhancements.
Organizations that can document
and market successful pain manage-
ment programs may increase their
admissions and market share, par-
ticularly of residents with the op-
tion of choosing their nursing homes
on the basis of quality indicators,
which are now publically available
online at http://www.medicare.gov/
NHCompare. These residents of-
ten have greater resources or bring
higher reimbursement rates that will
increase the nursing homes revenue.
For example, a home with a reputa-
tion for effective pain management
with better quality measures on
pain could potentially draw higher-
paying short-term postoperative and
post-hospitalization clients, who are
increasingly a higher percentage of
the overall nursing home population
(Grabowski, OMalley, & Barhydt,
2007). Patient outcomes demonstrat-
ing effective pain management could
be used as a tool to market the facil-
ity to local physicians and hospital
discharge planners. Likewise, other
community-based health organiza-
tions (e.g., hospitals, clinics) may
target local nursing homes that have
a comprehensive pain program for
residents who need this specific care
(e.g., postoperative care, diabetic
neuropathy, trauma diagnoses). With
the growing movement toward pay-
for-performance mechanisms, out-
Copyright SLACK Incorporated
 TABLE
HYPOTHETICAL FIRST-YEAR COSTS OF A PAIN MANAGEMENT PROGRAM IN AN AVERAGE-SIZEDa
NURSING HOME
Staff/Supplies/Training Description Approximate Cost
External pain management Provides baseline assessments, staff training, design/modifications $12,000
consultant to documentation forms, and follow-up evaluation ($100 per hour;
120 hours)
Staff training (paid educational 50 certified nursing assistants ($12 per hour; 2 hours) $1,200
time)b 10 licensed practical nurses (LPNs) ($21 per hour; 4 hours) $840
6 RNs ($28 per hour; 4 hours) $672
1 advanced practice nurse (APN) ($39 per hour; 4 hours) $156
Educational supplies Photocopy machine and printer supplies, plus handouts, folders, $335
and paper for 67 staff members
Information resources Books, guidelines, manuals $500
RN or APN project manager 0.25 full-time equivalent (FTE) $25,000
5 LPN unit leaders 0.50 FTE released time (4 hours per week per LPN) $18,000
Total $58,703

a
100 beds.
b
National average salary rates for each job classification.

come data demonstrating a highly
effective pain management program
could also position a facility for ad-
ditional revenue from quality-ori-
ented bonuses.
Cost Savings. Cost savings are
associated with increasing efficien-
cies and effectiveness. One of the
best ways to accomplish increased
efficiency is to standardize care pro-
cesses, which is often best done by
following clinical practice guidelines
(Boyd et al., 2005). The American
Geriatrics Society Panel on Pharma-
cological Management of Persistent
Pain in Older Persons (2009) and
the American Medical Directors As-
sociation (2009) have recently pub-
lished clinical practice guidelines on
pain management for older adults.
These guidelines provide an excellent
start for nursing homes to establish
a cost-effective program. Unfortu-
nately, nursing home staff do not
always adhere to clinical practice
guidelines or evidence-based best
practices (Jablonski & Ersek, 2009).
The use of information technology
has also been found to provide cost
savings; therefore, nursing homes
should consider that electronic med-
ical records, telemedicine, and point-
of-care charting may contribute
greatly to cost savings (Luck et al.,
2007). Use of online resources such
as those available at http://www.
GeriatricPain.org or http://www.
nhqualitycampaign.org (the site for
the Advancing Excellence in Amer-
icas Nursing Homes campaign) can
also be useful in improving quality
while potentially reducing staff edu-
cation costs. Both groups provide
best practice resources specifically
for nursing homes, and http://www.
GeriatricPain.org has download-
able forms and PowerPoint slides
that can be customized to individual
nursing home needs. All of these
resources can help nursing homes
standardize their programs, reduce
inefficiencies within the program,
and decrease costs while improving
quality.
Cost Avoidance. Cost avoidance is
the process of averting costs brought
on by poor care processes that can af-
fect nursing homes both directly and
indirectly. Poor pain care may result
in unnecessary rehospitalizations
(Boutwell, Jencks, Nielsen, & Ruth-
erford, 2009; Grabowski et al., 2007),
prolonged rehabilitation, increased
staffing needs and caregiver burden,
fines, and increased risk of lawsuits
(Frank, Kleinman, Ciesla, Rupnow,
& Brodaty, 2004; Herrmann et al.,
2006).
The most dramatic examples of
cost avoidance are lawsuits associ-
ated with untreated or poorly man-
aged pain. Shapiro (1994) described
five legal liability concerns: (a) health
care providers liability for inappropri-
ate pain management, (b) health care
providers liability to parties for injury
caused by treatment for patients pain,
(c) distinguishing between euthanasia
(physician-assisted suicide) and pain
management, (d) payers liability to
patients due to cost-containment deci-
sions, and (e) manufacturers and pro-
viders liability for any risks or side ef-
fects of pain medication. Providers and
clinicians are at risk for lawsuits when
they do not meet the standard of care,
that which is usual and customarily
provided by qualified caregivers (Sha-
piro, 1994). Case law has demonstrat-
ed that most claims against nursing

JOURNAL OF GERONTOLOGICAL NURSING VOL. 38, NO. 2, 2012 47

Figure 2. Number of long-stay nursing home residents with moderate to severe pain from 2005-2009.
Note. AE = Advancing Excellence in Americas Nursing Homes.
Reprinted with permission from Advancing Excellence in Americas Nursing Homes.

Figure 3. Number of short-stay nursing home residents with moderate to severe pain from 2005-2009.
Note. AE = Advancing Excellence in Americas Nursing Homes.
Reprinted with permission from Advancing Excellence in Americas Nursing Homes.

homes are associated with negligence
or what staff failed to do, such as fail-
ure to effectively manage pain through
use of evidence-based practices.
Efforts at tort reform have placed
caps on liability claims over the past
several years. Despite that, there are
cases where the lack of quality pain
management was considered elder
abuse (Rich, 2004). There have also
been cases of alleged elder abuse
due to inadequate pain management
from which nursing homes have re-
ceived citations.
Other care processes that are at-
tributable to cost avoidance are
associated with delayed recovery
due to excessive pain that increases
the length of stay (Fox, Sidani, &
Brooks, 2009), ineffective pain man-
agement requiring greater nursing
hours secondary to more patient
complaints, and additional pain-
related symptom management such

48 Copyright SLACK Incorporated

as nausea and lack of sleep, as well
as depression that is often associated
with chronic pain (Won et al., 1999).
Transfers to the emergency depart-
ment and actual inpatient hospital-
izations are also potentially avoid-
able costs (Grabowski et al., 2007;
Ouslander et al., 2010). Patients who
cannot get their pain needs met in the
nursing home are often transferred
to the emergency department and
occasionally admitted to the hospital
at great expense to the system (Luck
et al., 2007). Each of these problems
can increase the cost of care, and fail-
ure to address these issues increases
the risk of quality-of-care complaints
and therefore the risk of lawsuits and
state or federal fines.
Laying a Foundation for the
Business Case
Initial work in making the busi-
ness case includes examining the
operational structures and pro-
cesses that exist in the nursing
home. The Sidebar outlines some
of the structures and processes
that should be considered when
making the business case. Nurse
leaders should first review each of
these steps to determine their in-
ternal capabilities to evaluate their
existing program. Second steps in-
clude meeting their administrator
to identify other internal resourc-
es to assist with the evaluation of
nonclinical areas. Schnelle (2007)
emphasized the importance of en-
suring that the following nursing
care processes are also consistent
with resident preferences: fre-
quency and consistency of care,
length of care, quality of staff in-
teraction during care, and how of-
ten care is provided. Knowledge
of the staff; appropriate policies,
procedures, and forms; availability
of nonpharmacological interven-
tions; information resources; and
availability of nursing leaders are
key components that should be as-
sessed in the evaluation (Keeney et
al., 2008; Leone, Standoli, & Hirth,
2009). In addition, leaders should
JOURNAL OF GERONTOLOGICAL NURSING VOL. 38, NO. 2, 2012
examine the systems and processes
that enhance workforce efficien-
cies (Schoenwald, Hoagwood, At-
kins, Evans, & Ringeisen, 2010).
Organizations need to ensure the
comprehensive pain management
program is consistent with all regu-
latory guidelines (i.e., F-Tag 309),
evidence-based care, clinical prac-
tice guidelines, and best practices.
Nursing homes may lack sophis-
ticated financial tracking systems
due to the costs of such programs,
making it more difficult to analyze
the costs associated with a compre-
hensive pain management program.
They may also lack the RN staff
needed to perform comprehensive
assessments, develop quality im-
provement systems, and track and
trend data. Therefore, nursing homes
that are committed to transitioning
toward a pain-free environment will
require some intentional investments
of time and resources to implement
an effective pain management pro-
gram; these additional costs should
be included in estimates.
Nursing home administrators
and nurse leaders who are com-
mitted to enhancing pain practices
and outcomes may initiate one, all,
or any combination of the cost-
effectiveness strategies but they
should ensure they are considering
issues related to quality as part of
the equation. Targeted pain man-
agement process improvement ini-
tiatives can be implemented by ex-
isting nursing home staff, if there
is sufficient administrative support
to allow staff to redirect adequate
time and effort toward meeting pain
management goals. However, given
the limited staffing resources in
most nursing homes, the addition of
an expert consultant, such as an ad-
vanced practice nurse with geriatric
and/or pain management expertise,
would expedite the process. The
Table provides a hypothetical ex-
ample of major costs that might be
incurred for first-year implementa-
tion of a pain management program
in a 100-bed nursing home.
APPROACH TO IMPROVING
PAIN MANAGEMENT
Nurse leaders must start the pro-
cess by conducting an assessment
of current pain management prac-
tices, identifying areas needed for
improvement, and then drafting a
plan to improve, similar to a SWOT
(strengths, weaknesses, opportuni-
ties, threats) outline. This plan is the
basis for evaluating costs. In the past
few years, several resources have be-
come available that aim to facilitate
developing a comprehensive and
evidence-based pain management
program. Using clinical practice
guidelines and other resources, as
referenced earlier, not only provides
evidence-based care guidelines but in-
directly promotes efficient processes
that reflect cost-effective care. One
of these resources that has recently
become available, GeriatricPain.org
(http://www.geriatricpain.org), is
a website focused on pain manage-
ment specifically for nursing home
staff. It is the result of a project pri-
marily funded by The Mayday Fund,
housed at Sigma Theta Tau Interna-
tionals Center for Nursing Excel-
lence in Long-Term Care. The site
provides best practice web-based
pain resources, including education-
al, assessment and management, and
quality improvement tools that are
evidence based and facilitate quality
pain assessment and management in
the nursing home setting.
Also available is an important pain
management quality initiative, the
Advancing Excellence in Americas
Nursing Homes Campaign, which
is an all-volunteer group composed
of more than 30 industry and pro-
fessional organizations dedicated
to improving the quality of care in
nursing homes (Advancing Excel-
lence Campaign Steering Committee,
n.d.). Improved pain management
has been one of the major goals of
the campaign since its inception. The
Advancing Excellence campaign pain
management goal is for nursing home
residents to experience minimal, if
any, pain. To help facilities reach this
49
 www.medicare.gov/NHCompare),
CMS Five-Star Quality Rating
KEYPOINTS System (https://www.cms.gov/
Bakerjian, D., Prevost, S.S., Herr, K., Swafford, K., & Ersek, M. (2012). Challenges in
CertificationandComplianc/13_
Making a Business Case for Effective Pain Management in Nursing Homes. Journal of
Gerontological Nursing, 38(2), 42-52. FSQRS.asp), and Advanc-
ing Excellence (http://www.

1 The purpose of this article is to address the conceptual domains

and processes that are important to improving quality of care and
reducing costs in a comprehensive pain management program.
nhqualitycampaign.org) websites.
High-quality pain management pro-
grams could decrease the chances of

2 Many barriers to effective pain management exist, including lack

of knowledge and clinical expertise of staff, insufficient education
and awareness of older adult patients and families, and ineffective
being included on the federal Special
Focus Facility list of nursing homes
that are identified and targeted for
use of existing processes and tools for pain management. their lack of quality-of-care im-
provements. All of these publically

3 Evidence-based tools and resources exist through free online re-

sources such as GeriatricPain.org and the Advancing Excellence
in Americas Nursing Homes Campaign.
available lists can potentially affect
institutional image, public percep-
tions, and market share. Avoidance

4 A strong financial and operational commitment from the nursing

home leadership is critical to the success of developing a compre-
hensive pain management program to support quality pain as-
sessment and management in nursing homes.
goal, the campaign provides several
online resources that can be used to
improve pain management.
The campaign collects pain data,
and analyses of those data suggest
that nursing homes are still far from
the intended campaign goals. Fig-
ures 2 and 3 show the overall preva-
lence for both long-stay (those who
live in nursing homes longer than
90 days) and short-stay (patients in
nursing homes after an acute hos-
pitalization) cohorts for the 2009
calendar year. While the prevalence
of pain for long-stay residents has
declined somewhat, pain for short-
stay patients has remained constant.
In fact, almost 1 in 4 short-stay resi-
dents still experience moderate to se-
vere pain, and the overall population
of residents with pain has actually
increased (Bakerjian, Gravenstein,
Benner, & Koren, 2009). This indi-
cates that pain is still a significant
problem in nursing homes, although
increased reporting may be a reflec-
tion of improved recognition of pain
through better assessment practices
and documentation.
The Advancing Excellence cam-
paign also has several evidence-based
process tools that are useful for eval-
uating the quality of a pain manage-
ment program. Nursing homes that
participated in the campaign and
chose pain as a goal showed better
outcomes in reducing moderate to
severe pain than those that did not
participate in the campaign; these
results support the effectiveness of
quality improvement (Baier, Butter-
field, Harris, & Gravenstein, 2008).
By using these various tools and
guidelines, most nurse leaders would
be able to identify the general areas
needed for improvement. Once these
areas are known, costs estimates for
each of the improvements could then
be started. It is possible that a clini-
cal nurse specialist consultant may
be needed to ensure that all factors
for the program improvements are
considered. In addition, getting as-
sistance from the administrator and
finance staff would be appropriate.
Recognition of Improving Quality of
Pain Management Care
An effective pain management
program can contribute to bet-
ter pain quality indicators on the
Nursing Home Compare (http://
of state and federal fines, penalties,
and sanctions provide additional op-
portunities for cost savings. Regula-
tions such as the proposed Nursing
Home Resident Pain Relief Act of
2011, various state statutes, and case
law have established that facilities
can only protect themselves from
lawsuits if they can demonstrate they
have provided care consistent with
regulatory guidelines and hopefully
best-practice recommendations.
Areas for Outcome Evaluation and
Future Research
Numerous potential research op-
portunities related to the business
case for a comprehensive pain man-
agement program would ultimately
help nursing home administration
establish high-quality, cost-effective
programs (Swafford et al., 2009).
Quantitative studies that examine the
cost benefits and cost effectiveness of
a comprehensive pain management
program will help geriatric leaders
understand which specific strategies
are most cost effective and can be
implemented effectively. Qualitative
research that examines the effects of
a pain program on residents, families,
and staff will also be helpful in under-
standing the role of improved pain
management on quality of life. Com-
parative effectiveness studies could
examine the relative effectiveness of
clinical factors such as pharmacologi-
cal and nonpharmacological inter-

50 Copyright SLACK Incorporated

ventions, nurse staffing, information
technology, and associated organi-
zational factors that affect cost and
quality. Nursing home leaders who
are embarking on a pain management
quality improvement project may
consider examining the effectiveness
of their program using research meth-
ods and then publishing their find-
ings. These types of quality improve-
ment or cost-effectiveness studies can
contribute greatly to the knowledge
within the field.
CONCLUSION
Pain management is a nurse-
sensitive process, and the lack of a
systematic and comprehensive pain
management program is a common
quality problem in nursing homes.
There is a paucity of knowledge on
the cost effectiveness or even the
costs of implementing a compre-
hensive pain management program.
Establishing a business case for high-
quality programs is challenging and
has not always yielded evidence in-
dicating that programs make good
business sense. It is time for health
care leaders in nursing homes to
take an active role in demonstrat-
ing the case for comprehensive pain
management. Consumers are in-
creasingly demanding high-quality
care; therefore, pain management is a
quality issue that cannot and should
not be ignored.
This article has suggested several
strategies for establishing an internal
business case to support implemen-
tation of a comprehensive pain man-
agement program in a nursing home.
Additionally, it is suggested that
nurse leaders take primary responsi-
bility in evaluating their existing care
processes and bring in administra-
tion and finance personnel to assist
with the cost analysis. This informa-
tion could be shared with other nurs-
ing homes at conferences or through
written manuscripts. Sharing the
systems, processes, and outcomes
of programs that carefully examine
the cost along with quality of pain
management will prove useful to the
JOURNAL OF GERONTOLOGICAL NURSING VOL. 38, NO. 2, 2012
nursing home industry and for those
residents who experience daily pain.
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ABOUT THE AUTHORS
Dr. Bakerjian is Assistant Adjunct
Professor, and Vice Chair, Family
and Community Medicine for FNP/
PA Studies, Betty Irene Moore School
of Nursing, University of California,
Davis, Sacramento, California; Dr.
Prevost is Associate Dean, Practice and
Community Engagement, University
of Kentucky, Lexington, Kentucky; Dr.
Herr is Professor and Associate Dean,
Adult and Gerontology Area of Study,
College of Nursing, The University of
Iowa, Iowa City, Iowa; Ms. Swafford is
John A. Hartford Predoctoral Scholar,
John A. Hartford Center of Geriatric
Nursing Excellence, Oregon Health &
Science University, Portland, Oregon;
and Dr. Ersek is Associate Professor, John
A. Hartford Center of Geriatric Nursing
Excellence, University of Pennsylvania,
School of Nursing, Philadelphia, Penn-
sylvania.
The authors disclose the following:
honoraria through CEU/CME provid-
ers (Dr. Bakerjian, Dr. Herr); payment
for speaking at Purdue University (Dr.
Bakerjian); and payment from the
Oregon Health Care Association for
a presentation on nursing home qual-
ity improvement related to pain (Dr.
Swafford). This project was supported by
The Mayday Fund and the Robert Wood
Johnson Foundation for Nurse Executive
Leadership Development.
Address correspondence to Debra
Bakerjian, PhD, RN, FNP, Assistant
Adjunct Professor, Betty Irene Moore
School of Nursing, University of Califor-
nia, Davis, 4610 X Street, Sacramento,
CA 95817; e-mail: debra.bakerjian@
ucdmc.ucdavis.edu.
Received: March 15, 2011
Accepted: November 7, 2011
Posted: January 20, 2012
doi:10.3928/00989134-20110112-01
Copyright SLACK Incorporated
Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.