Alan White, Ph.D., Barbara Manard, Ph.D., Deborah Deitz, BSN, Terry Moore, MPH, RN, Donna Hurd, MSN, Christine Landino, MSW, MPH, Jennie Harvell, M.Ed. Show
Abt Associates, Inc. This report was prepared under contract #282-98-0062 between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and Abt Associates. For additional information about the study, you may visit the DALTCP home page at http://aspe.hhs.gov/daltcp/home.shtml or contact the ASPE Project Officer, Jennie Harvell, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. Her e-mail address is: . 1.0 Policy Context and Study DescriptionThe quality of nursing home care is a major concern for state and federal policymakers, and regulators as well as consumers and industry representatives. This concern has prompted many public policy initiatives intended to improve the quality of care. 1.1 Policy ContextThe traditional approach to ensuring adequate quality of nursing home care is regulatory--through the long-term care (LTC) survey and certification process. The Omnibus Reconciliation Act (OBRA) of 1987 strengthened federal requirements for the LTC survey and enforcement requirements, establishing a set of minimum standards that nursing homes must meet in order to gain (and retain) Medicare and Medicaid certification. The Centers for Medicare and Medicaid Services (CMS), formerly the Health Care Financing Administration, contracts with state survey agencies to monitor compliance with these standards through annual facility surveys, and states are primarily responsible for regulating the quality of nursing homes. The Federal Government pays 100 percent of the costs of Medicare skilled nursing facility surveys and 75 percent of the costs of Medicaid nursing facility surveys. Despite the survey process, quality of care in nursing homes continues to be a concern, and the effectiveness of the survey process continues to be debated.1 Enforcement regulations have been criticized by providers and consumer advocates alike as either too stringent or not stringent enough. Many critics say the problem is the lack of consistency in how the survey, certification, and enforcement processes are implemented--that wide intra and inter-state variation exists in the number and type of deficiencies issued, scope and severity ratings assigned, and penalties imposed.2 Some states have established programs to improve nursing home quality through information and guidance to nursing homes on ways to improve quality of care--both generally and in relation to a facility's particular problems. In some states, these programs are intended to "raise the bar" by providing technical assistance to facilities so that they can perform at levels that exceed regulatory standards. Similarly, the Federal Government has recently implemented nursing home quality improvement programs provided by the Quality Improvement Organizations (QIOs, formerly known as Peer Review Organizations) under contract to CMS. The CMS effort also includes a public reporting component. As of November 2002, CMS made available, through the QIOs, technical assistance to nursing homes in all states and began posting quality measures for nursing homes, in addition to other facility-level information, for nursing facilities nationwide through the Nursing Home Compare website (http://www.medicare.gov/NHCompare/Home.asp). The impetus for this recent federal initiative is similar to that of some of the states-- to stimulate the nursing facilities to improve performance through the provision of technical assistance and to furnish consumers with comparative information with which to make an informed choice about initial or continued residence in a given facility. How these federal nursing home quality improvement efforts will interact with state TA programs has not yet been determined.
1.2 Study DescriptionThe purpose of this study is to inform state and federal policymakers about the characteristics, objectives, and implementation of the quality improvement programs states have implemented. A particular study goal is to provide information to states that may wish to develop such programs in their state. Originally, the study was to focus solely on Technical Assistance (TA) programs that provide on-site consultation, training, and/or sharing of best practices with nursing facility staff. Eight states (Florida, Maryland, Maine, Michigan, Missouri, Texas, Virginia, and Washington) currently have active TA programs.3 The design and focus of these TA programs vary across states, but they share several defining characteristics:
Our study focus expanded, however, as our research revealed state-initiated quality improvement initiatives in addition to TA. In addition to providing TA, some states also train nursing home providers on compliance with regulations and other topics, and make information available to consumers through public reporting of information. To select states to be included in this study, we collected basic information about the quality improvement programs in states through a combination of discussions with stakeholders and a review of relevant written information. The study focused on a group of states that had state-initiated quality improvement programs that included aspects of technical assistance and that were not reimbursement or payment related. The states we ultimately selected were Florida, Iowa, Maine, Maryland, Missouri, Texas, and Washington.4 All except Iowa have formal TA programs in place. Iowa was added because it had particularly interesting other quality improvement initiatives.5 Our data are from structured discussions with key stakeholders in each study state. Key representatives from the state agency responsible for the quality improvement programs were contacted to arrange face-to-face meetings with stakeholders. Participants in these discussions included state Survey and Certification Agency Directors and staff; Directors of Quality Improvement Projects and staff; state Medicaid Agency Directors; representative(s) of for-profit and not-for-profit nursing home associations; nursing home providers; and consumer advocacy representatives and the state's long-term care Ombudsmen. Most discussions lasted about two hours. Our research team encouraged the organization, agency, or nursing facility involved to include as many of their staff as they thought would be interested or have valuable information to share. In several states, the research team was able to observe a portion of a TA survey visit on site. Typically at least two researchers participated in each site visit--one researcher would guide the discussion; the other would take notes on participants' responses. The discussions focused on the following topics:
Appendix A contains summary reports documenting each state visit. We found a range of philosophical influences combining to shape quality improvement efforts in particular states. Major influences include state legislatures, personal involvement of individual state legislators in long-term care issues, campaigning by consumer advocacy organizations, complaints from the industry about "over-regulation" by both state and Federal Governments, and a considerable body of research documenting the inadequacy of care delivered to residents of U.S. nursing facilities.6 These issues are often interrelated--an interrelation that serves as the catalyst for a state's decision to embark on its own quality initiative.
2.0 Approaches to Ta Programs: Motivation and Program DesignWe were interested in two particular question related to program design: (1) the motivation for states to implement a TA program rather than some other type of quality improvement initiative; and (2) the extent to which states used a formalized design approach to guide development of their TA programs. 2.1 Choosing the TA RouteAlthough each state had its own set of reasons for designing and implementing its particular quality improvement programs, a similar driving force seemed typically to be behind the decision to implement a TA program--dissatisfaction with the survey process--stimulating a desire to "try something new" or focus attention on quality in a way other than regulation. This was particularly true for states with a TA program focused on improving care practices, and the cases of Missouri and Maryland illustrate this point. The impetus in Missouri came from a set of pilot tests run in 1999 to study the impact of using advanced practice nurses to improve resident outcomes through technical assistance. This research showed that providing feedback on quality through reports and education was insufficient to improve clinical practices and resident outcomes.7 It found, further, that a stronger intervention of expert clinical consultation coupled with comparative feedback was needed to improve resident outcomes. Missouri also noted that TA visits were beneficial because they (1) recognize that facility staff are stretched to the limit, making it difficult for them to keep current on the latest clinical information; and (2) provide support to facility staff who want to do a good job, but need some ideas and encouragement (see Appendix A for more details on the Missouri TA program). The impetus for Maryland's quality improvement programs, enacted in 2000, was a series of events and activities both within and outside the state over the preceding ten years. In 1989, the media reported on deplorable conditions in a Maryland nursing facility and subsequent scandals and multiple nursing facility closures over the next three years precipitated a 1999 General Accounting Office (GAO) study that found the complaint investigation process was unacceptably slow (the GAO made similar findings in other states). In 1999, the negative personal experiences of several influential state senators with respect to Maryland nursing homes, along with damaging testimony before the state legislature by Maryland Department of Health and Mental Hygiene/Office of Health Care Quality (OHCQ) staff on the issue of complaints, was influential in leading the legislature into tying passage of a nursing home funding bill to creation of a Nursing Home Task Force to study quality and oversight in Maryland. The Task Force began meeting during the summer of 1999 and presented their recommendations in January 2000. In May 2000, a broad Nursing Home Reform Package was enacted in Maryland that did not focus simply on strengthening regulations and sanctions, but also included provisions specifically addressing quality improvement such as the addition of a technical assistance program through a required "Second Survey". 7. See Rantz MJ, Popejoy L, Petroski GF, Madsen RW, Mehr DR, Zygart-Stauffacher M, Hicks LL, Grando V, Wipke-Tevis DD, Bostick J, Porter R, Conn VS, Maas M (2001). "Randomized clinical trial of a quality improvement intervention in nursing homes. The Gerontologist 41(4), 525-538. 2.2 Approaches to Program DesignThe literature on quality improvement strategies includes several potential design frameworks or paradigms for use in designing an effective quality improvement program.8 While differing in detail, all include a series of logical steps to (1) assess or identify the nursing facility quality problem at hand; (2) evaluate or analyze the issue in order to determine the best approach to resolving it; (3) create a plan for implementing the program design or activity intended to improve the problem; (4) define the interaction between TA staff and the survey agency; and (5) evaluate whether the intervention as designed and implemented actually resulted in quality improvement. In an effort to categorize the quality improvement programs in the study states, we looked at the extent to which each program had been developed with this general sequence of steps in mind. We found only two states (Texas and Missouri) that had followed such a strategy in full, with rigorous program designs that included an evaluation component. Other state programs were developed through an essentially ad hoc process.9
3.0 Ta Programs in the Study States: Overview and Critical DecisionsThis chapter provides brief overviews of the six technical assistance programs we studied, and the critical decisions program designers and implementers must make. Chapter 4 places these TA programs within the wider context of state quality improvement programs more generally. 3.1 The TA Programs in BriefAll of the technical assistance programs we reviewed, with the exception of programs in Washington and Maine, have been in existence for less than two years. It is important to keep in mind that the relatively short life of these programs, combined with the fact that many of them were introduced at the same time as other quality improvement initiatives, limits our ability to draw firm conclusions about how program characteristics relate to quality of care outcomes. Florida (Quality of Care Monitoring Program): The Quality of Care Monitoring Program was established in 2000, and is part of and administered by the Florida Agency for Health Care Administration (AHCA). AHCA also includes the state survey and certification agency. The Quality of Care Monitoring Program was designed to create "a positive partnership between the state regulatory agency and nursing homes and ultimately yield improved quality of care to residents." Technical assistance is provided by Quality Monitors who make quarterly, mostly unannounced, visits to facilities, and offer educational resources and performance intervention models designed to improve care. Quality Monitors also interpret and clarify state and federal rules and regulations governing nursing facilities, and seek to identify conditions that are potentially detrimental to the health, safety, and welfare of nursing home residents. The role of the monitors has expanded since the program was first implemented, to include a number of more regulatory-related processes. Quality Monitor staff now review compliance with minimum staffing and risk management requirements; preside over facility closures; and train new surveyors. Funding for the Florida technical assistance program is split between state general revenues and a portion of punitive damage awards that are set aside to improve nursing home quality. Maryland (State Technical Assistance Unit--Quality Assurance Survey): The State Technical Assistance Unit was established in 2000, to monitor compliance efforts and provide information about best practices. The unit performs required, unannounced, annual Quality Assurance Survey (the so-called "Second Survey") at each Maryland nursing facility. The Quality Assurance Survey Unit Team, which is separate from and independent of the survey staff, consists of five nurses, one dietician, and a manager. The Second Survey is intended to be collegial and consultative rather than punitive, and its separation from the survey and certification process is intended to preserve confidentiality. Funding for the Maryland Quality Assurance Survey is obtained from state general revenues. Washington (Quality Assurance Nurses): The Washington state Quality Assurance (QAN) program has been implemented since the late 1980s. QAN visits are made to all nursing homes in the state. In addition to providing technical assistance (or "information transfer," as the state calls it), 31 nurses conduct reviews of MDS accuracy; operate as surveyors, both conducting regular surveys and occasionally serving as complaint investigators; conduct discharge reviews to determine if resident rights are maintained when discharged/transferred; and serve as monitors of facilities in compliance trouble. The Washington State QAN program is unique in that it is the only state that has implemented a nursing home technical assistance program as part of it Medicaid "medical and utilization review or quality review" program (for further discussion of this financing mechanism see Chapter 5). Under this funding authority the state received a 75 percent federal match rate. Maine (Consultant Nurse for Problem Behavior Residents): The technical assistance program in Maine is the smallest program in our study. In existence since 1994, the program in Maine consists of a single nurse, who provides statewide consultation and educational in-services to any facility on problem resident behaviors. The goals of the program are to (1) help facilities provide better services and reduce the risk of abuse and neglect, especially for those residents with problem behaviors who are more at risk; and (2) reduce the number of residents discharged because a facility cannot deal with their behavior. Maine financially supports the Consultant Nurse program by drawing on funds from fines collected through the imposition of civil money penalties (CMPs). Missouri (Quality Improvement Program for Missouri): The Quality Improvement Program for Missouri was developed, and is implemented and operated by the University of Missouri-Columbia Sinclair School of Nursing. The location of Quality Improvement Program at the University of Missouri supports and underscores the independence of the program from the State Survey Agency. The Quality Improvement Program has seven nurses who provide confidential consultation to assist nursing homes with their quality improvement programs. The Quality Improvement Program is not mandatory. Since the program began in 2000, 45 percent of the nursing homes in Missouri have elected to receive this assistance. Funding for the program comes from the Missouri Department of Health and Senior Services and is financed through a combination of nursing home bed taxes, annual licensing fees, and fines collected through CMPs. Texas (Quality Monitoring Program): The TA Quality Monitoring Program in Texas was implemented only in April 2002 and is a mandatory program for all nursing homes. The Quality Monitoring team includes registered nurses, pharmacists, and nutritionists, who conduct unannounced and unsolicited visits to facilities. Quality monitoring visits are scheduled based on a determination of the level of risk at each facility. Quality Monitors conduct individual resident and facility-level reviews to assess the quality and appropriateness of care in selected areas (e.g., restraint use, incontinence care, and toileting plans). The Texas Quality Monitoring Program is unique in that it has developed evidence-based protocols for quality improvement. Within the Quality Monitoring program, there is also a rapid response team, made up of one or more quality monitors. The Rapid Response Teams sometimes make unannounced to facilities that have been identified as being particularly problematic. They also visit facilities that request their assistance. The funding for the first two years of the Texas Quality Monitoring program was $2.7 million, with the program funded with 50 percent state funds and 50 percent federal funds.10 In order to fund its share of this program, the State transferred 50 FTEs from the survey to this new program. As part of the legislation that established the Quality Monitoring program, an additional 32 FTEs were transferred from actual survey work to other components of the state's Quality Outreach Program, including the state's Rapid Response teams, provider education, and liaison with providers. Table 1 provides more detail on these state TA programs. Additional details on the programs in each study state can be found in Appendix A. 10. See Chapter 5 for more information on the provisions of the Social Security Act that Texas used to secure federal funds for its Quality Monitoring program. 3.2 Critical Decisions in the Design and Implementation of TA ProgramsStates have a series of critical decisions to make as they develop and implement a TA-type program to improve nursing facility quality of care. Our discussion here reviews how our study states made these decisions. In so doing we highlight the range of choices the study states made and the implications of those choices for program operation, focus, and likely impact. Program Focus: Improving Care Practice or Regulatory ComplianceThe focus of a state's TA program is a fundamental choice that influences all the subsequent program design decisions. States tended to choose one of two directions. One group of states created programs that focused on direct promotion of quality improvement through efforts to assist facilities in improving their care practices. In the other group of states, the focus of the TA programs promoted quality through an emphasis on monitoring compliance with survey and certification requirements. Programs in this second group of states do offer technical assistance to facilities on quality related issues beyond the scope of the survey and do not have the punitive aspects of the survey process. However, they tend to focus more on monitoring care and regulatory compliance than on helping facilities to improve their care processes. The distinction between the foci of the two groups of states was conspicuous, and state representatives, providers, and consumer advocates talked extensively about the orientation of the TA program. Although not explicitly stated by any of the stakeholders with whom we spoke, several statements taken together made it clear that some states believe that emphasizing monitoring and enforcement of survey requirements can and does raise the level of care quality. For example, in Washington, a state with a TA program that emphasizes regulatory compliance, virtually all of those with whom we spoke--state personnel, providers and consumer representatives--reported that one of the best things about the state's QAN program was its close ties to the survey. These stakeholders expressed a belief that TA programs should emphasize regulatory compliance, and be linked with survey activities and staff. Other states viewed such linkages as conflicting with what they saw as the primary aim of the TA program, through the provision of an alternative to the survey process. In states that focused on improving care practices, the belief was that when the focus was on improving quality of care for residents, regulatory compliance would logically follow (rather than the other way around). Programs with a Focus on Directly Improving Care Practices The majority of our study states (Maine, Maryland, Missouri, and Texas) have chosen to focus their TA programs directly on helping nursing facilities to improve their care practices, using an approach that is separate from the LTC survey process.
Programs with a More Regulatory Focus The focus of the TA programs in Washington and Florida is more on promoting regulatory compliance.
While the primary focus of the types of programs (i.e., those with a focus on improving care practices vs. those with a focus on promoting regulatory compliance) is clear, there is a certain overlap between these two types of programs. For example:
Relationship Between the Survey and TA ProgramsClose Ties In two of our study states we found close relationship between the TA program and the state survey agency.
"Relative" Independence In some of the study states there was relatively more independence or separation between the TA program and the state survey agency.
Total Separation In our study states, Missouri was the only one state in which there was total separation between the TA program and the State Survey Agency.
Reporting of Findings from TA Visits to the Survey AgencyStudy states fell into two groups here. In more than half of them (Florida, Maryland, Missouri, Texas) TA findings are not formally reported to long-term care survey staff. Hardly surprisingly, the states that have steered clear of regulatory-based TA fall into this group. No Formal Reporting to the Survey Agency Maryland TA staff do not share findings with the State Survey Agency unless very serious violations (i.e., situations where conditions in the facility are causing residents actual harm or placing them in immediate jeopardy.) At the time of our visit, TA staff reported this has only happened once. The regular process when violations are identified during a TA visit is to have the Quality Assurance team bring these to the attention of the nursing home staff and require a plan of correction. In Missouri, TA visits are also confidential (except in the rare cases of immediate jeopardy or actual harm to residents). No details are reported to the survey agency (not even which facilities were visited). State law mandates that the TA nurses report any situations where there is actual harm or immediate jeopardy. They must inform the facility about the issue of concern; and then must contact the LTC survey agency to discuss it. TA staff report that such a situation has never come up. In Florida, TA staff do not share information gathered during the TA visit with surveyors, but they will bring concerns about facilities that are performing poorly to their supervisors within the state survey office, as well as report on non-compliance related to staffing and risk management. TA staff are advised to call the state hotline to report instances of immediate jeopardy. Formal Reporting to the LTC Survey In Maine, copies of the TA reports go to the TA supervisor (who works in the survey office) and are available to surveyors. In Washington, TA staff report all serious violations to, and share all findings with survey staff. In Texas, Quality Monitor reports are available over the IntraNet to surveyors and are reviewed as part of preparation for surveys. Requiring TA Staff to have Surveyor TrainingStates span the spectrum on the issue of whether TA staff should have surveyor training. In Maryland and Washington, TA staff are required to have surveyor training, while Maine and Missouri have purposely chosen not to hire surveyors. In Florida and Texas, surveyor training is not required but some TA staff who were previously surveyors have been hired as part of the quality improvement program. States Requiring Surveyor Training Some states use TA staff that have either survey expertise and/or surveyor training.
States Not Requiring Surveyor Training Some states do not require that TA staff have either survey expertise and/or training.
11. Originally, TA staff went through the risk management training offered by the University of South Florida, However, risk management training was not provided for those hired when subsequent legislation increased the number of Quality Monitors. Facility Participation in TA ProgramsMandatory Programs In all our study states except Maine and Missouri, TA initiatives were mandatory for all Medicare and Medicaid certified long-term care facilities in the state. This decision is legislatively imposed in some states, such as Florida. In other states, such as Washington, the mandate is part of state utilization review requirements, which necessarily apply to all Medicaid facilities but not Medicare only facilities. In Maryland, there is no legislation specifically mandating a quality related survey, but state regulations require two annual surveys to be performed for each facility, and the state has chosen to focus its "Second Survey" on quality improvement activities that include technical assistance and sharing of best practices. The frequency of TA visits in states with mandatory programs varies. In Maryland, TA visits are performed yearly at each facility. In Texas, all facilities have at least one TA visit per year with additional visits prioritized to target those considered likely to be at risk for a poor survey, based on factors such as quality indicator data and previous survey results. Facilities can also request a site visit if they need guidance about an area of care. Florida also ties the frequency of visits to quality concerns. Florida's original legislation was similar to Texas, calling for annual TA visits to all facilities, with more frequent visits to troubled facilities. Current legislation mandates quarterly visits to all facilities and continues the policy of providing additional visits to poorly performing facilities. In Washington state, Quality Assurance Nurses are required by regulation to visit each Medicaid nursing facility at least quarterly. Voluntary Programs The two states with voluntary TA programs in the study are Maine and Missouri. These programs focused on quality improvement through consultation focused on helping facilities to improve their care practices rather than through regulatory compliance. In Missouri, TA visits are provided by nurses employed by the University of Missouri and are voluntary, confidential, and consultative. The consultative focus allows TA nurses to emphasize standards of care and to work with facility staff on improvement efforts that are specific to their facility and resident needs. In 2001, there were 459 site visits in 212 different facilities. This included 164 nursing homes, 20 intermediate care facilities, and 85 residential care facilities (note that some facilities fell into multiple categories). Since the program began in mid-2000, about 270 of the 600 (45 percent) nursing facilities in Missouri have participated in the TA program.12 Missouri's QIPMO program encourages facility participation through the efforts of the staff to publicize the program. The TA staff in Missouri believes that their involvement in support group activities helps increase provider awareness of and interest in the TA program. TA staff coordinates and facilitates monthly MDS Coordinator support group meetings. These meetings aim to (1) improve MDS coding accuracy, (2) enhance job satisfaction for MDS Coordinators and (3) increase overall staff retention rates. In addition, the program receives referrals from surveyors. Maine's TA program provides behavioral consultation statewide to any long-term facility upon request. Its focus is on improving resident outcomes through a combination of consultative and educational support. There are 126 nursing facilities in Maine, with 7,309 residents reported as of Spring 2001. Maine's TA nurse reports visiting 181 residents from July 2000 through June 2001, and 169 residents from July 2001 through June 2002. No records have been kept to indicate the number of facilities that have been visited. In Maine, nursing home providers appreciate that the TA is free, that it is not connected to the LTC survey, and involves all facility staff in the process. Some referrals come through the Ombudsman caseworker, who contacts the TA nurse directly or suggests that the facility contact her. But the majority of referrals come from facilities themselves. The TA nurse describes the goals of her services as "to assist staff in dealing more effectively with difficult behaviors by giving them a better understanding of the resident and why the behaviors are occurring, making recommendations, involving them in team problem solving where their input is valued, and providing them the education that will enable them to do their jobs more effectively and safely--as well as improving quality of care and ultimately quality of life for the resident."13 She prioritizes responses to facility requests based on the severity of the problem. Visits are generally made within two weeks of the request.
Focus of TA VisitsThe focus of TA visits varied across states.
14. See Appendix B for an example of the Missouri Show-Me QI report. The Nature of the TA InterventionDissemination of Best Practices "Best practices" as applied to nursing facilities is a general term that refers to a range of activities centered on identifying excellence in clinical practice. The methods by which the study states identify best practices and disseminate this information, and the audience for whom they are intended, vary significantly. Study states varied in terms of what was describe as best practices--in how best practices are defined, where they originate, and how these practices are used by the state's other quality improvement programs. Some states define a best practice as an expert-derived protocol that should be adopted by facilities to raise standards of practice. Others define a best practice as an innovative idea originating at the facility level that was seen as potentially valuable to other facilities. Still other states use both definitions. Examples of Best Practice protocols disseminated by study states are included in Appendix C. In Texas, a panel of academic, clinical, and medical experts were used to develop evidence-based clinical practice guidelines that are a core feature of the Quality Monitoring Program. The initial focus has been limited to a small number of areas (e.g., restraint use, incontinence care, hydration). The intent is for the assistance provided by TA staff to reflect the consensus of pooled experts, not the opinion of an individual TA nurse or the survey agency. Quality Monitors provide information regarding best practices and how to achieve them, give feedback to facilities regarding the degree to which the facility is providing care consistent with the best practice protocols, and help the facility identify system changes that could result in greater use of best practices. The best practices are also posted on the QM Website (described in more detail in section 4.2.) TA staff in Maryland, Florida, Washington, and Missouri also disseminate best practice information. In these states, however, this consists of information that the TA staff has collected from personal reading, interactions with other facilities, and personal networking. None of the information has been formally endorsed by the state or collected together and posted in a single location.
TA Staff Composition Florida, Missouri, Washington and Maine require their TA staff to be registered nurses (though not necessarily experienced in long-term care). Only Texas and Maryland's TA teams mimic the survey teams' composition, which includes other disciplines as well as nursing. Visit Structure The structure of the TA visits varies widely across states and in some states across geographic region within a state. The latter is true of Maryland, where the TA visit is still evolving, and in Washington, where TA staff have the flexibility to organize the visit according to the specific issues to be addressed that day. The facility personnel they meet with also vary. TA staff may meet with the facility risk manager (Florida), for example, or QA coordinator (Maryland), as well as with other members of the facility quality assurance team (e.g., social workers, nurses, therapy, administration) during each visit. Texas has a formal debriefing session (or exit conference) that TA staff conduct with each facility visited. Visit length also varies, by state and by issue being addressed on-site. For example, a Maine TA visit lasts about four hours. A Maryland visit takes two days, with about six hours spent in resident medical record review to reconcile what the staff is saying with what has been recorded in the charts. The remaining time is spent reviewing the QA plan, and interviewing key facility staff. Staff may be interviewed to assess the facility's concurrent review process (a requirement related to QA plan). In Florida, the TA staff nurse places signs in facilities she is visiting, inviting residents and families to speak with her. The Maryland, Texas, and Washington TA visits may involve resident interview and observation, as well. 3.3 SummaryParticipants noted that there are both positive and negative aspects of having the TA program affiliated with the state survey program. TA staff who also function as surveyors are perceived as having greater authority, more regulatory knowledge, and better able to effect positive changes in resident care. Regulatory-related information given by TA staff who also function as a surveyor is expected to be more consistent among TA staff and between TA staff and surveyors. Sharing TA reports with survey staff may help inform and focus both survey and TA efforts. However, housing the TA program within LTC survey agencies, having TA staff function in both TA and survey roles, and/or sharing information between the TA and survey programs gives rise to understandable provider concerns. In states with close ties between survey and TA staff, providers were less willing to be involved with the TA program. They reported being less forthright during visits, and less willing to give honest feedback on TA evaluation forms, given that the same TA staff might be performing their agency's next survey or complaint investigation. In addition, in states where TA staff acted in both roles, many participants noted that TA staff are sometimes diverted to survey tasks, reducing both the regularity and frequency of TA visits. Whether TA staff should have surveyor training depends, in part, on whether or not there is a significant regulatory component to the TA program. In states where the TA program is closely linked to the survey agency, TA staff obviously need surveyor training. Interestingly, in states where TA staff do not perform survey tasks but have been recruited from the survey agency, discussants commented that former surveyors often have trouble "changing hats." In states that are unambiguously focused on quality first, clinical expertise is seen as more important than knowledge of regulations. However, facilities in these states say it bothers them when TA staff are unable to provide interpretive regulatory guidance. We also learned that some providers were overwhelmed by the amount and complexity of the TA information provided, particularly in states where evidence-based practice was a goal (Texas and Missouri). The frequency of visits is also another design decision states must make. Providing quarterly visits to all facilities in a state, as Washington and Florida are required to do, is a Herculean task given current TA staff levels. In fact, in both states, state officials and some providers reported they were not receiving quarterly visits. Some Washington providers said that TA visits occur much less frequently than quarterly, and state program administrators agreed that certain geographic regions have experienced fewer visits due to the demands of the LTC survey and certification schedule. In Florida, high TA staff turnover and the increasing demands on TA staff time for survey-related tasks were blamed for the quarterly TA schedule slipping in some regions. According to providers and other stakeholders we talked with during our visits, several factors probably contribute to facilities not participating in voluntary TA programs: (1) Some nursing home chains have their own quality improvement program and they feel that additional consultation is unnecessary and/or potentially confusing. (2) Some facilities do not understand the purposes and goals of the program, or are not aware that the program exists. (3) Some facilities associate TA with the LTC survey process and do not wish to be subjected to what they assume will be additional scrutiny. (4) Some facilities are focused only on survey and certification and lack interest in a program whose goals are not focused on improving survey results. (5) Some facilities do not have the resources either to devote to non-mandated quality improvement efforts or to allow staff to benefit from TA activities. The nature of the TA intervention varied across, but was intended promote what each state defined as best practices. Interventions disseminated by the states included: evidenced-based care practices, expert opinion and information gathered by TA staff, and/or facility-nominated best practices. These programs are too new, and the data are insufficient, for any conclusion to be drawn as to which approach is more effective in promoting quality (which all agree is the ultimate goal). Only Missouri, and to a lesser extent Maryland, had made any attempt to evaluate their programs at the time of our visit, and no state has tested the effectiveness of one approach over another.15 On the one hand, states that focus primarily on regulatory compliance have, in effect, increased the number of times the state agency is in the facility evaluating facility performance. This gives the state greater knowledge of day-to-day facility operations, but may not improve the relationship between providers and the regulatory agency, which historically has been troublesome in many states. On the other hand, states that focus primarily on improving nursing home care practices encourage consultation between monitors and providers, allowing facility staff to enter into collaborative relationships with state staff. These collaborative relationships may enhance problem recognition and solving. Providers, especially those not part of a larger network, appreciate the expertise and knowledge that can be provided by TA staff, who are not part of the potentially adversarial survey and certification process. 15. For more details on the results of Missouri's evaluation, see Chapter 6. 4.0 the Wider Context of State-Initiated Quality ImprovementIn addition to the TA programs reviewed in Chapter 3, the states we studied all had initiated additional state-initiated quality improvement efforts. In addition to technical assistance programs, the four most commonly initiated practices included:
This section presents information on each of these four program categories, including the differing approaches states have taken to implement them, the nature of their interaction with TA programs, the perceived positive and negative aspects of each program, and their potential impact on quality. Readers interested in learning more about these programs, as well as the other activities listed in Table 2, are directed to the state reports included in the Appendices at the end of this document. 4.1 Public ReportingOver the past several years, a number of initiatives aimed at giving consumers and other members of the public access to information about nursing home quality have been implemented. In November 2002, as part of its Nursing Home Quality Initiative, CMS began posting on its Nursing Home Compare website [www.medicare.gov/NHCompare/Home.asp] information for each Medicare and Medicaid certified nursing home. The information includes indicators of each facility's performance as measured by ten quality measures. The Nursing Home Compare website benchmarks the facility's performance on these indicators against all nursing home providers in a state and nationally. The Nursing Home Compare website also includes provider-reported staffing information and was recently expanded to include complaint information. In addition to public reporting efforts by CMS, 20 states have instituted their own public reporting initiatives.16 Of the seven states reviewed for this project, four (Florida, Iowa, Maryland, Texas) have developed a public reporting system. Each of these states makes the data accessible over the Internet. (Internet website addresses and examples of the data reported by these states are shown in Appendix D.) The public reporting systems in these states vary in the type and degree of posted information. Each is intended to provide information to assist consumers in understanding the quality of care provided in each Medicare or Medicaid certified facility in that state. In Florida, Iowa, and Texas, the websites allow access to information about survey results, giving users the ability to drill down to increasingly detailed data about each nursing home--including lists of deficiencies on the most recent survey and a summary of the facility's regulatory compliance history.
16. Nursing Home Quality: A National Overview of Public Reporting Programs January 2002 Rhode Island Department of Health, Health Care Quality Series Number 11. Interaction with TA ProgramsThe public reporting systems in Florida, Maryland, and Texas are used to help inform quality improvement efforts discussed in Chapter 3.
Positives and Negatives of Publicly Reported InformationStakeholders with whom we spoke discussed the positive and negative implications of publicly reporting information on nursing home quality. State officials believe the greatest benefit of publicly available nursing home quality reports is to help nursing home residents, their families, and informal caregivers make informed decisions when selecting a nursing home or evaluating the care provided in a particular facility. Some stakeholders in most of the states indicated that the report cards had increased consumer access to public information. However, consumer advocates noted that consumers frequently do not know that the reports exist, may not have Internet access, or may not be proficient in navigating the Internet. There has been no analysis of how often report cards actually influenced decisions about nursing home placement.
Some stakeholders also expressed concern that websites may not be designed to optimize consumer access to, and use of, these sites. Some provider associations suggested that more collateral materials should be included on websites to aide consumer understanding of the information posted. States reported difficulties in balancing the provision of sufficient information to assist consumers in making more informed decisions, while not overloading consumers with data. For example:
The websites were also reported to provide easy access to information on nursing home quality to advocates, the provider industry, legislators, and other public policy makers. The websites in Florida, Iowa, Texas and Maryland each includes a disclaimer that the information on their website should not be used as the sole basis for nursing home selection. However, some stakeholders expressed concern that users of these websites do not sufficiently explore the meaning of posted information. For example,
While some stakeholders indicated that the information reported on a state's website was generally current and accurate, others expressed concern that some websites were designed to collect old information while other sites simply could not be kept current. For example:
Consumer representatives were concerned that a good rating on a report card--or even a bad one--could misinform consumers. For example, some advocates in Florida believe that giving the worst facilities in the state even a one-star rating was misleading. In Texas, the lowest ranking indicates facilities that have the 'most disadvantages' with respect to quality indicators or a 'substandard quality of care' with respect to survey findings, so this is less of a concern. Many providers indicated that greatest benefit of the public reporting was the ability afforded to them to use a good quality rating as a marketing tool. Providers in several states said the reports allow good nursing homes an opportunity to receive the praise they deserve and distinguish them from poorer performing facilities. While CMS and some of the states have posted nursing home performance information for the last several years, providers expressed concern about the impact of posting this information on the availability and costs of nursing home liability insurance. Providers and their associations in Iowa, Florida, and Texas reported that some liability insurance companies were choosing not to write policies for facilities with a higher number of deficiencies or that have poor quality indicator scores, and others have increased rates to the point where facilities report they can no longer afford this insurance. While the survey deficiency information has always been public, the availability of this information on state public reporting systems makes it easier and less costly for insurers to identify poor performing facilities. The states of Iowa, Florida, and Texas have convened task forces to examine the liability insurance issue. Potential Impact on QualityIn the study states, state officials expressed their hope that public reporting of deficiencies will improve quality by stimulating competition and sparking change in facility culture. Of the states we studied, however none have formally evaluated the impact of their public reporting programs on quality of care. Maryland plans to perform an analysis on the impact of their public reporting initiative, and the state has made some modifications to the public report based upon feedback. Doubts were already being voiced in several states we visited, however, about the potential effectiveness of public reporting to effect change. As discussed above, some stakeholders questioned whether the report cards could have an impact on consumer decisions, since the public is not sufficiently aware that the report cards exist. In most states, agency staff are able to measure how many people use the website, although they cannot identify whether these are consumers, policymakers, researchers, or others. Further, as suggested above, additional education may be necessary to raise consumer awareness of the report cards and promote consumer use of available nursing home quality information more generally. Another factor that may limit the impact of report cards on quality improvement is that nursing home placement choices are limited in some states. However, some providers and other stakeholders voiced the opinion that access to quality reports is increasingly important in states where falling nursing home bed occupancy rates are expanding consumer choice. Of most fundamental importance is the concern is that public reporting of inadequately risk adjusted quality indicators could limit access for heavy care patients even at the best performing facilities. For example:
Although public reporting has been promoted as a means for facilities to identify problem areas and target initiatives aimed at improving quality of care, none of the providers we spoke with identified it as such. Some stakeholders expressed concern that it is primarily the facilities already considered to be top-performing that will make necessary changes, while a certain percentage of providers in each state simply do not have the resources to initiate or sustain these improvement programs. In Florida, for example, consumer advocates noted that some facilities have been on the Watch List many times, and that this does not appear to have provided sufficient motivation for those facilities to do a better job. Nonetheless, some stakeholders with whom we spoke suggested that public reporting is a necessary, but, not sufficient step to improve nursing home quality. 4.2 Best Practice Dissemination ProgramsAs discussed in section 3.2, study states varied in terms of what each described and promoted as "best practices" and how these practices are incorporated into their quality improvement/technical assistance programs. In addition to best practice dissemination through the TA program, many of the study states also initiated additional activities to recognize and disseminate information about best practices in nursing homes in their state.
Potential Impact on QualityAs with public reporting, none of the study states has made any systematic attempt to measure the impact their best practices programs have had on quality. During discussions with providers and state program staff we received several comments on their potential impact, however.
4.3 Training/Joint Training ProgramsAs discussed in section 3.2, all study states include informal provider education during facility visits as one component of the technical assistance offered caregivers and administrators, and all but one include provision of some type of formalized training in their quality improvement efforts. This section describes state-initiated training programs that are directed at improving the quality of nursing home care that are separate from their quality improvement/technical assistance programs (as described in section 3.2). Determining the topics for training is done by different methods in different states. A common approach is for states to select training topics simply by identifying areas where providers were perceived to be experiencing the greatest difficulties. In some states (e.g., Texas), at least part of the training is focused on areas that are most frequently cited as deficient. In some states, political pressures created the impetus for specific training initiatives (e.g., the Alzheimer's training program in Florida--see below). Generally, most states reported that training sessions are well attended, even though they are mostly voluntary. Two of the states visited, Iowa and Texas, have made provision of joint training to providers and surveyors a key part of their quality improvement program. Examples of training programs used by study states can be found in Appendix E. When joint training is offered, the goals include an effort to provide a common knowledge base for surveyors and providers. Participants in these joint training programs reported that having both surveyors and providers in the same room has met with some resistance from both sides and may have had a chilling effect on discussion. Despite this, many said they believe joint training is essential, so that both providers and surveyors receive the same information--and that such sharing, even though stressful at the time, may ultimately help improve the surveyor-provider relationship, leading to better communication during the survey process. In addition to the joint training described above, the Texas Ombudsman and his staff, who already have a presence in facilities, are conducting training on resident centered care. The issue of restraint use was chosen as a focus of this training because it is a long-standing issue with consumer advocates, because restraint use is notably high in Texas and currently a major concern of the Texas Department of Health, and because the Texas Department of Insurance identifies restraint use as a risk factor for liability issues. The program is intended to dispel myths about perceived benefits of restraints in resident safety and to help educate staff and families about alternative options. Program content has been coordinated with the best practice protocols developed for the Quality Monitor program. The program is set up in three modules: training all ombudsmen volunteers (60 staff oversee the 850 volunteers), followed by those volunteers training facility administrators and key staff, and then the volunteers/staff educate families on the topic area. There is no mandatory requirement for facilities to participate. The goal of the program is to have 10 percent of facilities adopt the program by August 2003. Texas will compare the use of restraints in nursing homes before and after its joint training. The training program will be considered a success if restraint use is decreased in 10 percent of the facilities that participated in the joint training program. It will not be possible, however, to separate the effects of this training from other quality improvement efforts in the state. Florida requires that all nursing home employees expected to have direct contact with residents with Alzheimer's Disease and related dementias receive a state approved training program. To provide this training, Florida employs a train the trainer model where one individual in each facility is trained by staff from the University of Southern Florida (USF) and then becomes the staff person responsible in that nursing home for training all other staff who may have contact with residents with Alzheimer's Disease and related dementias. USF has also developed a compact disc aimed at training licensed practical nurses in dementia-related care issues and also disseminates best practices via the web. Providers reported that they found the training program most helpful for nursing aides and for facilities that do not have a specific dementia care unit. Some expressed the opinion that facilities should be able to choose for themselves the training that would most benefit their facility. Some providers said mandatory training felt more like a "big brother is watching" regulatory approach than a valuable educational program. Maine, a state with many rural facilities spread over a wide geographic area, brings training to the facilities. The single nurse who staffs the TA program developed this approach. While participating in a facility closure, she observed that educational programs available to long-term care staff were generally held outside the facility, requiring a facility representative to travel to the program and then carry the information back to the staff. She envisioned a program that would provide educational and support services in the environment of the residents and the direct care staff. She has developed seven such in-service programs, which she conducts at facilities on request. Topics include Practical Hints for Caregivers of Alzheimer's Disease and Elopement Risk Factors and Prevention. These programs are very popular and are often scheduled six months ahead. The state Licensing and Certification Division reported that 90 percent of all homes in the state sent staff to one of the workshops held in the past two years. Discussant comments on provider training tend to be positive, expressing the idea that the sharing of knowledge should at least provide facilities with useful information related to quality improvement. Potential Impact on QualityNo state included in our study has yet done any formal analysis to of the impact of state sponsored training programs. Anecdotally, nursing home administrators and clinical staff reported that training combined with regulatory interpretation and practical applications in nursing home care improved quality. Providers reported making changes in their caregiving practice after participating in a seminar in which a surveyor provided interpretation of regulations, followed by a panel discussion and presentations by facilities of their best practices in that particular clinical area. Some stakeholders said they thought training was a critical but insufficient element of good quality care. 4.4 Facility Recognition ProgramsTwo of the states we studied (Florida and Iowa) have developed and initiated reward and recognition programs as part of their quality improvement efforts. The goal of these programs is to recognize facilities doing exemplary work. Examples of Facility Recognition Programs can be found in Appendix F. Florida and Iowa use a similar process for selecting facilities for quality awards. Residents, family members, members of resident advocacy committees, or other health care facilities can make nominations for the awards. In Florida, nominations can be also made by the state Agency for Health Care Administration, provider organizations, ombudsman, or any member of the community. Nominations are presented to a governor-appointed committee that includes the state's long-term care ombudsmen and other consumer advocates, and health care provider and direct care worker representatives. Both states make efforts to eliminate conflict of interest among committee members. Both states specify criteria that must be met for a provider to receive a "recognition" award. Nominees must provide a description of the facility's best practices and the resulting positive resident outcomes, or the unique or special care or services (nursing care, personal care, rehabilitative or social services) provided by the facility to enhance the quality of life for its residents. Performance data (e.g., the facility's "report card" or assigned "quality of care rank" within the applicant's geographic region) are used in determining the facility's quality. Florida facilities must meet a number of additional rigorous criteria to qualify for the quality award including: strict standards of performance on survey inspection results (i.e., no Class I or Class II deficiencies within the previous 30 months of application), no history of complaints, high level of family involvement, satisfied consumers as measured by an assessment of consumer satisfaction, low staff turnover rates, and the provision of in-service training. Further, facilities are required to demonstrate financial soundness as evidenced by a formal financial audit. Many stakeholders believe that this latter criterion eliminates most facilities from consideration because most facilities may unable to afford such an audit and providers that have been the subject of bankruptcy proceedings (or whose parent organization have been the subject of bankruptcy proceedings) during the preceding 30 months are disqualified. In both states, following selection of the finalists by the awards panel, onsite reviews are made to verify the accuracy of the information on the nomination form. When the awards are confirmed, the governor presents a certificate to the facility administrator in a recognition ceremony. Some consideration has been given to providing additional rewards to award-winning facilities, such as an extended survey cycle, but these have not been implemented due to federal policies mandating that nursing facilities be surveyed every 12 to 15 months. Despite Florida's more detailed and complex requirements for consideration, a similar percentage of facilities in both states (between one and two percent) have received the quality awards. Iowa's numbers are limited because the state legislation permits only two facilities from each congressional district to be recognized as award winners each year. In addition to the quality award described above, Iowa also presents a Certificate of Recognition to any facility that receives a deficiency-free survey. The certificate is intended to acknowledge the "hard work and dedication" of the facility's staff in meeting the established standards of care, and is considered a way of providing positive feedback to providers with good survey results. Positive and Negative ResponsesIn general, the response to the quality award programs has been positive. State nursing home regulators assert that the awards provide facilities with incentives to focus on quality improvement and create a benchmark for others to strive to meet. Providers, who appreciate any program that rewards good facilities, see the awards as a powerful marketing tool that can boost revenues and possibly reduce liability insurance costs. Advocates welcome any type of information that can help consumers make informed decisions about nursing home placement. However, a number of concerns were also voiced about the award programs:
Potential Impact on QualityWhether the quality recognition programs have any effect on promoting quality resident care remains unanswered. Both the programs are relatively new and neither state has performed any formal analysis of their impact on quality. Interestingly, however, most stakeholders express the opinion that the programs are unlikely to affect quality. "Window dressing " and "a warm fuzzy for providers" were typical of the comments received. Many with whom we spoke were concerned that the programs focused on high-performing facilities instead of the facilities most in need of assistance concerned. One stakeholder noted, "Only 5 percent of facilities are eligible--we worry about the other 95 percent." Some stakeholders voiced the opinion that the awards, like a good rating on the facility report card, are a marketing tool which becomes increasingly relevant when bed occupancy is lower. When occupancy rates are lower, consumers may have more choice about where to go, and, thus, providers may compete by improving quality. 5.0 Funding Mechanisms for Quality Improvement ProgramsTypically, states are focused on "quality assurance" activities in nursing homes--that is monitoring and enforcing compliance with nursing home requirements. Most states have avoided nursing home quality improvement activities, particularly technical assistance programs, in large part, due to the limited availability of federal funds for quality improvement and confusion about what funding sources may or may not be used to support such programs. This chapter reviews the current funding mechanisms used by states to fund state initiated quality improvement including technical assistance programs. It also provides a guide to potential funding sources for states considering quality improvement programs, by describing current and possible future legislation that may provide for federal funding for such programs. We start this discussion by reviewing the requirements for and limits on the Medicare and Medicaid survey and certification programs. 5.1 Federal Funding for Survey, Certification, and EnforcementFunding for Survey, Certification, and EnforcementCMS pays for Medicare and Medicaid nursing home survey, certification, and enforcement activities using a price-based budgeting process. Under the price-based methodology, national standard measures of workload and costs are used to project individual state workloads and budgets. Payments to states are based on allowable costs up to a ceiling of 115 percent of the national average. If states exceed this average, their payments are frozen at the previous year's level for that facility, unless the state can successfully justify the causes for costs exceeding 115 percent.17 At the time of our study, no states have argued that their costs in excess of the 115 percent ceiling should have been allowable.18 The federal budget for fiscal year 2003 includes almost $250 million for state survey and certification activities.
Survey Requirements--Sections 1819 and 1919(g)The Social Security Act specifies the federal requirements for monitoring compliance of Medicare and Medicaid nursing home providers under Sections 1819 and 1919(g). Compliance with these statutory requirements and implementing regulations is assessed using a survey, certification and enforcement process defined in statute and regulation. Medicare and/or Medicaid certified nursing homes are surveyed at least once every 15 months. The Federal Government is required to conduct surveys of Medicare SNFs. The Federal Government contracts with state survey agencies to perform this activity and pays 100 percent of the allowable state survey costs for Medicare SNFs (Section 1864(b)). In addition, as permitted by statute, the Federal Government contracts with states to conduct Medicaid surveys. The federal law requires that the Federal Government pay states 75 percent of survey, certification, and enforcement costs for Medicaid facilities (Section 1903(a)(2)(D)). CMS restricts the amount of technical assistance that surveyors can provide. According to a December 2002 program memorandum (see Appendix G), surveyors "should not act as consultants to nursing homes…" but should "provide information to the facility about care and regulatory topics that would be useful to the facility for understanding and applying best practices in the care and treatment of the long-term care residents." This information exchange is not considered by CMS to be consultation with the facility, but rather "a means of disseminating information that may be of assistance to the facility in meeting long-term care requirements." In addition, the memorandum refers to Section 2727 of the CMS State Operations Manual (see Appendix G), which states: "It is not the surveyor's responsibility to delve into the facility's policies and procedures to determine the root cause of the deficiency or to sift through various alternatives to suggest an acceptable remedy. When the State Agency conducts a revisit, it is to confirm that the facility is in compliance with the cited deficiencies, not whether it implemented the suggested best practices, and has the ability to remain in compliance." Reference information regarding best practices may be provided to "assist facilities in developing additional sources and networking tools for program enhancement," but surveyors are instructed not to "act as consultants to nursing homes." Guidance on the types of allowable survey and certification activities that may be eligible for a federal matching payment is found in the State Operations Manual (Section 4100-4109). There is no provision that explicitly permits use of federal survey and certification funds for any technical assistance or quality improvement programs like the programs in the states that we visited. Educational Programs--Sections 1819 and 1919(g)(1)(b)As part of the statutory Medicare and Medicaid nursing home survey and certification requirements, each state must "conduct periodic educational programs for the staff and residents (and their representatives) of [nursing facilities] in order to present current regulations, procedures, and policies under this section." Technical assistance programs that include a regulatory focus may be considered such "educational programs." For Medicaid, a 75 percent federal match is available for approved costs. The Federal Government pays 100 percent of the costs of such programs for Medicare SNFs. Nursing Home Enforcement--Sections 1819 and 1919(h)Federal law enumerates several remedies that may used to promote compliance with nursing home requirements. In Medicaid, the remedies range from penalties to incentives for high quality. Some of the Medicaid remedies may be applicable to state initiated quality improvement programs. These are discussed below. Medicaid Civil Monetary Penalty (CMP) Funding--Section 1919(h)(2)(A)(ii)States collect CMP funds from Medicaid nursing facilities and from the Medicaid part of dually certified skilled nursing facilities (SNFs) not in compliance with federal conditions of participation. Federal CMP funds are collected from Medicare-only facilities and the Medicare portion of dually participating nursing facilities. The Social Security Act (Section 1919(h)(2)(A)(ii)) provides that CMP funds collected by a state from nursing homes19 must be applied to the protection of the health or property of residents of nursing facilities that the state finds to be deficient.20 CMS has given states flexibility in determining the appropriate uses of CMP funds as long as those funds are used "in accordance with the law and in a consistent manner." (Source: August 8, 2002 Memorandum from Steve Pelovitz, Director of CMS Survey and Certification Group, to State Survey Agency Directors, see Appendix G).21 Some states have used CMP funds for their technical assistance or other quality improvement programs. CMP funds must be applied to residents in facilities that have been found deficient. CMS has given states flexibility in determining when a facility must have been deficient to be eligible for a CMP-funded program. According to the August 2002 program memorandum:
These CMP funds are state, not federal, funds. States may use the state-share of CMP collected from Medicaid-only certified nursing facilities and from the Medicaid part of dually participating facilities for any project that directly benefits facility residents in facilities that have been found deficient. These CMP funds could be used to prevent continued noncompliance by nursing facilities through educational or other means including the development and dissemination of videos, pamphlets, or other publications providing best practices. Other uses could include the use of consultants to provide expert training to deficient facilities. CMP funds collected from Medicare-only facilities, the Medicare part of dually-participating facilities, and the federal share of state collected CMPs are returned to the Treasury.
Incentives for High Quality Care in Medicaid--Section 1919(h)(2)(F)The Social Security Act describes the enforcement tools that may be used to promote compliance with requirements. One tool, for which federal funding is available, are state established public recognition programs to recognize facilities that provide the highest quality of care provided to Medicaid residents. According to the statute, "a state may establish a program to reward, through public recognition, incentive payments, or both, nursing facilities that provide the highest quality of care to residents..." The law indicates that expenses incurred in such incentive programs, "shall be considered to be expenses necessary for the proper and efficient administration of the state plan under this title." These costs are eligible for a 50 percent federal match. 5.2 Federal Funding Sources for TA and Other Quality Improvement Programs Being Used by Study StatesThere are other Medicare and Medicaid provisions that could provide federal funding for TA or other quality improvement programs. These provisions are described below. Medical and Utilization or Quality Review--Section 1903(a)(3)(C)(i)This section provides for a 75 percent federal match for the costs incurred "for the performance of medical and utilization or quality review by a utilization and quality control peer review organization." This section covers activities performed by state Quality Improvement Organizations (QIOs), which have similar characteristics to the TA programs in several study states (see Chapter 8 for more details on this program), and is used by Washington state to secure matching funds for its technical assistance program which is operated as part of the state's medical utilization program. Funding for Skilled Professionals and Support Staff--Section 1903(a)(2)(A)This provision provides for a 75 percent federal match for costs "attributable to compensation or training of skilled professional medical personnel, and staff directly supporting such personnel, of the state agency or any other public agency." Iowa uses this provision to maximize federal funding for its public reporting, joint training, and provider recognition programs. Funding for Nurse Aide Training--Section 1903(a)(B)This provision allows a 50 percent federal match of the costs associated with nurse aide training and competency evaluation programs, regardless of whether the programs are provided in or outside nursing facilities. Florida uses this provision to maximize federal funding for the Florida Alzheimer's Training Program for nurse aides who are employed by or have an offer of employment in a nursing home. 5.3 Potential Funding Sources not being Used by Study StatesState Consultative Services--Section 1902(a)(24)This section provides that funding is available to nursing facilities (and other provider types) for "consultative services by health agencies and other appropriate agencies of the state" to assist them in qualifying for payment under the Medicare and Medicaid programs, or establishing the fiscal records needed to determine payment on "account of care and services furnished to individuals." This provision could be used to support programs, for example, related to the MDS (e.g., training in completing the MDS accurately). A 50 percent federal match rate is available for such consultative services. This section of the Social Security Act was not used to obtain federal funding by any of our study states. Assuring Service Delivery in the Best Interest of Medicaid Recipients--Section 1902(a)(19)According to this section, Medicaid state plans must "provide such safeguards as may be necessary to assure that eligibility for care and services under the plan will be determined, and such care and services will be provided, in a manner consistent with simplicity of administration and the best interests of the recipients." This section provides a 50 percent federal match and potentially could be used to fund state-established web pages or other sources of consumer information on nursing homes, although we are not aware of any states that have actually received federal funding for such efforts under this section. Proper and Efficient Administration of the State Plan--Section 1903(a)(7)This provision allows federal funding, subject to 1919(g)(3)(B) for 50 percent of the amounts expended by states (as approved by the Secretary) for the proper and efficient administration of the state plan. Information, Counseling, and Assistance Grants--Section 4360 of OBRA '90This provision permits states to receive funding for grants for programs related to providing education to Medicare beneficiaries. The law indicates that the purpose of such grants is to provide "information, counseling, and assistance relating to the procurement of adequate and appropriate health insurance coverage" to Medicare beneficiaries including providing "information that may assistance in obtaining benefits …under titles XVIII and XIX…" One potential use of these grant funds may be for public reporting systems that provide consumers with information regarding nursing homes. The FY 2002 appropriation for this program was $12.5 million. State allocations are made using a formula that takes into account the number of beneficiaries in rural areas and the number of Medicare beneficiaries relative to the state's total population. For large states (e.g., Florida and California) the average grant award is about $500,000. For smaller states (e.g., North Dakota and Missouri) the grant award is about $125,000. None of the study states indicated using this section to secure federal funds for their quality improvement programs. 5.4 Funding Sources Used for Identified Quality Improvement ProgramsIn general, in the states that we studied we found that federal survey funds had not been used for technical assistance programs but had been used for other types of quality improvement activities. As discussed in Chapter 3, only two of the technical assistance programs in our study--the programs in Washington and Maine--receive any federal funding. The funding sources and amounts for each of our study state's technical assistance, best practice, training, and facility recognition programs are discussed below.
5.5 Proposed Legislation Affecting Funding for Quality Improvement ProgramsTwo bills are currently in the U.S. Congress that, if passed, will provide additional authorization for funding state initiated technical assistance programs. Nursing Home Staffing and Quality Improvement Act of 2001 (H.R.118)The Nursing Home Staffing and Quality Improvement Act, introduced in the House Committees on Ways and Means and Energy and Commerce, would authorize the Secretary of the Department of Health and Human Services (HHS) to provide grants to states for the purpose of improving the quality of care furnished in nursing homes operating in the state. The bill would provide financial assistance for recruiting, retaining, or training nursing staff. State technical assistance programs may qualify for funding under these grant programs, since the legislation would permit funds to be used for bonuses to nursing homes that meet state quality standards; and for any other nursing home staffing and quality improvement initiative approved by HHS. Under the bill, Title XI of the Social Security Act would be amended to establish a Nursing Facility Civil Money Penalties Collection Account that would be used for awarding grants under the Act. This bill was introduced in January 2001. In February 2001, it was referred to the House Subcommittee on Health, and there has been no further action on it since then. Medicare and Medicaid Nursing Facility Quality Improvement Act of 2002 (H.R.4030)This legislation, introduced in March 2002 by Rep. Dave Camp (MI), would amend the Medicare and Medicaid statutes to modify the federal survey and certification process for nursing facilities. The bill would allow states to apply for waivers to the survey and certification requirements specified in Section 1819(g) of the Social Security Act. These states would develop "innovative quality measurement and oversight systems that differ from those presently required by federal law." According to the language of the bill, waiver requests are to be approved if they demonstrate "significant potential for improving the quality of care, quality of life, and safety of residents." According to the bill, up to eight states could receive authorization to create such alternative systems. The bill would eliminate rules that prohibit surveyors from making recommendations to improve nursing care. The legislation does not include authorize a specific funding amount or source. The bill (H.R.4030) has 15 co-sponsors and has been endorsed by both the American Association of Homes and Services for the Aging (http://www.aahsa.org/public/ press_release/PR221.htm) and the American Health Care Association (http://www.ahca.org/brief/nr020322.htm). In April 2002, the bill was referred to the House Subcommittee on Health in the Committee on Energy and Commerce, for a period to be determined by the committee chairman, and there was no action on this legislation between April 2002 and May 2003. 6.0 Effectiveness of Technical Assistance ProgramsA rigorous assessment of the effectiveness of state-initiated technical assistance programs is not possible at this time for several reasons:
In addition, while states expressed a general interest in measuring effectiveness of their quality improvement efforts, most have not developed a systematic evaluation plan and have been unable to identify acceptable criteria for measuring the impact. Although, intuitively, states believed that TA has a positive impact, uncertainty about an appropriate measure, along with the unknown influences of other ongoing programs, may mean that the impact of these TA programs on quality is never known. As an example, Florida said they have considered looking at changes in deficiencies, but have not been able to arrive at a suitable measure. A decrease in the number of deficiencies cited, a decrease in overall scope and severity, or a decrease in the number of citations have been considered as possible measures but none has been proven as reliable measures. The known inconsistency of survey results on these and similar measures adds to the state's reluctance to use any of them. Florida is also aware of the impact staff turnover has had on program effectiveness and sustainability, making them hesitant to begin an evaluation that does not take turnover into account. 6.1 Previous Studies of the Impact of Nursing Home Quality Improvement ProgramsPrevious studies have provided mixed evidence regarding the effectiveness of nursing home quality improvement programs similar to the TA programs that we studied. A CMS study (1998) evaluated two nursing home quality improvement programs that were accompanied by reasonably strong evaluation designs. One program, an extremely labor intensive intervention to reduce incontinence, resulted in a reduction in incontinence rates, but these gains were not sustained after the external research staff stopped providing feedback to the participating nursing homes. The study found evidence that the other intervention, the Ohio Pressure Ulcer Prevention Initiative, was not effective. A Commonwealth Fund evaluation of the Wellspring quality improvement model27 found several positive outcomes (e.g., improvement on federal survey and lower staff turnover), but there was no clear evidence of improvements in clinical outcomes based on Minimum Data Set (MDS) quality indicators. These results suggest that it may be difficult to change the organizational and care practices within nursing homes that impact resident outcomes. However, it is not possible to tell whether the mixed results of these previous evaluations are the result of an actual inability of the programs to result in improvements in quality or an inability of the available data to measure changes that may have actually occurred. A major challenge in measuring the effectiveness of any nursing home intervention is the difficulty in constructing valid quality measures. Absent any primary data collection, the two data sources that are available for measuring program effectiveness are the MDS and survey deficiency data. Both of these data sources have significant limitations for measuring quality of care, making it nearly impossible to draw definitive conclusions about the impact of specific interventions. These data limitations also limit the ability to compare the relative impact of nursing home programs with a quality improvement focus vs. those that focus on the survey and certification process. The MDS has two potentially significant types of limitations:
As noted by Walshe (2001), differences in deficiency rates across states (or regions within states) and changes in deficiency rates across time may reflect real differences in quality of care.28 But they also may be the result of differences in the stringency, scope, or implementation of the survey process.29 It is not possible to disentangle these two effects. According to an OIG report (1999), inconsistency in the survey process results from unclear guidelines that may contribute to different interpretations by surveyors when citing deficiencies, differences in the level of supervisory review for survey reports, and high turnover among surveyors. Due to these data limitations, little is known about the effectiveness of either TA programs or the survey and certification process, or about whether quality is improved more by investments in quality improvement or enforcement programs.30
6.2 Formal Assessment of TA Impact Among Study StatesMissouri is far ahead of other states in using systematic data to measure the impact of its TA program. Missouri's TA program began in 1999, when a pilot test demonstrated that providing written reports to nursing facilities on their quality improvement status was not enough to motivate changes in processes that would improve resident outcomes. The researchers who performed the pilot test noted that on-site expert TA, particularly when delivered as a series of on-going visits, was most effective in changing resident outcomes. Since the program's inception, staff have used the MDS-based quality indicators developed by the Center for Health Systems Research and Analysis (CHSRA) to measure the impact of their TA program on resident quality of care and quality of life. Although the quality of MDS data has improved, as familiarity with the tool has increased and data edits have been implemented by individual states and CMS, there is still considerable confusion around the coding of some items. Recognizing the potential for problems in the MDS data early on, Missouri developed standardized training materials for the MDS and mandates that anyone offering MDS training in the state utilize those materials. Their TA nurses also provide monthly support groups for MDS coordinators, as a forum to clarify issues regarding MDS coding. In addition to analyzing median quality indicator scores, the program staff analyze trends for the 90th and 95th percentile, so that the effectives of the program in improving outcomes for low-quality facilities can be understood. Analysis of data since the implementation of the TA program across all facilities participating in the program demonstrated improvement in 16 quality indicators, declines in only six.31 The following are the indicators that have improved:
Several quality indicators have gotten worse in Missouri since the implementation of QIPMO, including behavior problems for high-risk residents, patients receiving nine or more medications, range of motion training/practice, and antipsychotics use in the absence of an appropriate diagnosis. Preliminary investigations by QIPMO staff suggest that these declines may reflect MDS coding issues rather than actual decline of care. Maryland is the only other state that has attempted to formally evaluate the impact of quality on a select number of indicators. According to Maryland Department of Health and Mental Hygiene/Office of Health Care Quality (OHCQ), the eventual evaluation will look at complaint rates, correlations between deficiency citations and areas targeted for facility quality improvement, and facility satisfaction with the Second Survey. 31. Missouri program staff have not compared outcomes for TA participants vs. non-participants because such a comparison would confound programmatic effects vs. selection effects, due to the non-random selection of facilities. 6.3 Informal Assessment of TA Impact Among Study StatesDuring state site visits, the research team asked about the perceived impact of the TA program in each state on the quality of life or quality of care of the residents. Only one state was able to report any empirical analysis of the outcome of their efforts. Thus, most of the information we present in this section is anecdotal, gathered during our discussions with stakeholders. State program staff and stakeholders were also asked to describe aspects of the program that worked well, aspects that could be improved, sustainability, and lessons learned. Combining this information helped us understand how the programs had been able to effect change in facility systems or processes related to quality improvement--although it was typically difficult to attribute those changes solely to the TA program. Here we describe respondents' impressions of how the various TA programs have improved resident outcomes, which factors make them effective, and what difficulties they see as inherent in measuring program effectiveness. Ongoing Feedback MechanismsThe informal feedback TA programs received from facility staff generally took the form of a paper questionnaire given to facility staff at the end of a TA visit, asking facilities to provide information rating the performance of the TA staff and how helpful the visit had been. Some facility staff in Florida and Washington, where TA staff also function as surveyors, told the research team that they are hesitant to give any negative feedback on these questionnaires for fear that the staff member making the TA visit might be conducting their next LTC survey or complaint investigation. Texas was the only state that reported using the Internet for feedback on its program. In Washington, the survey staff holds quarterly forums with executives from the nursing home industry to discuss issues related to quality. Maryland state officials reported using the information collected as feedback on the TA program's first year to establish the focus for the second year's visits. Informal Assessment of Impact on Quality of Care and Quality of LifeMaine, Texas, Florida, Maryland and Washington all reported anecdotal comments on the impact of their TA program on resident quality of life and quality of care issues. For long running TA programs like Maine's and Washington's, participants made relatively strong statements on the impact of their programs. Maine's program was praised by every participant as improving the quality of life for the affected residents. Providers believed that the quality of life for the residents referred to the behavioral consultation program was definitely improved, because staff were able to provide better care to a difficult population. Anecdotal feedback from survey staff, the ombudsman, and facilities indicated that the consultations have led to changes in plans of care that have had positive results for both residents and staff. LTC survey staff from the state indicated that, based on informal feedback, the education and support given to staff has decreased medication use among the residents and the number of discharges due to behavioral issues. In Washington, program staff reported that they believe the TA program is positively affecting outcomes and quality because of informal feedback they receive from providers and stakeholders. Providers and ombudsmen with whom we held discussions noted ways in which they thought the TA program positively affected quality. For example, one provider stated that a good TA nurse can help facilities prioritize quality problems and can help new Directors of Nursing and facility staff to improve quality. An Ombudsman stated that the TA program has a positive effect because it promotes taking care of problems at an early stage. Many respondents viewed good performance on the survey as indicating better quality and indicated that TA visits helped facilities perform better on the survey. Comments on programs implemented more recently were more tentative, especially in Texas, with many respondents adopting a "wait and see" attitude. On the positive side, in every state there were participants who said the TA program was helpful, was a good resource for clinical and/or regulatory information, had taught or helped providers improve a skill, and represented a welcome change from the traditional adversarial relationship between provider and LTC survey staff. Providers reported that in many cases they value the consultative advice provided, saying that for some it has changed the relationship between the state and providers for the better. Participants reported learning investigative and analytic skills from TA that they are then able to use to review current facility processes. The shift in focus from deficiencies to quality improvement is also seen as positive. Some survey agencies even reported that providers have fewer complaints about the survey process. Negative comments are more specific to the individual state program. Lack of consistency between surveyor and TA information was noted as a problem in Washington and Florida. In Florida particularly, providers noted that TA staff hired when the program was initially legislated were former surveyors receiving a promotion, but that those brought in as part of subsequently legislated program changes were not experienced in long-term care, geriatric clinical issues, or the regulations--and thus were less helpful to providers. Florida providers also noted that the value and usefulness of the TA program, which reflects program staff and leadership, appears to vary considerably by region. Both Florida and Washington discussion participants reported problems with the frequency and regularity of TA visits. In each state, visits are mandated to occur on a regular basis, but sometimes do not, leading to distrust of program staff and perceptions of reduced effectiveness. In both these states, TA staff are also utilized for surveyor tasks. Lastly, in Missouri and Texas, providers said they are occasionally overwhelmed by the amount and complexity of information provided by the TA program. Missouri TA staff are advanced practice nurses employed by the university school of nursing, who utilize clinical studies as guidance for providers. In Texas the TA staff promote expert evidenced based practice guidelines developed by academic, clinical, and medical experts. Respondents in Texas reported being often uncertain how to use all the information and for how much of it they will be held accountable. The Florida and Washington programs, as noted, both involve TA staff functioning in multiple roles. Washington's TA staff act as surveyors on occasion and Florida's TA staff monitor facilities that are closing or in immediate jeopardy. In these states, facilities said they need to be aware of these differing functions and that, depending on the situation, the role of the TA and relationship with the facility may change. These seeming areas of overlap between TA and enforcement are seen by some to have a positive impact on quality, adding "teeth to be able to penalize facilities that don't perform." But others see them as negatively impacting the relationship and any atmosphere of openness between the facility and agency staff. Respondents from states where TA staff performed multiple roles made the point that where there are competing demands on staff who perform both roles, the TA role is often the one that suffers. More work is needed to evaluate which strategies most effectively change the culture of care giving. 7.0 Suggestions from Study States to Others Considering Quality Improvement ProgramsWe asked providers, state program administrators, and consumer representatives in each of our study states for general guidance advice they would offer other states considering quality improvement programs. We also asked for specific suggestions based on lessons they learned in relation to programs initiated in their states. The following list summarizes general guidance from state administrators to states considering developing a QI initiative:
7.1 TA ProgramsMany respondents offered advice related to the structure and function of TA programs, particularly regarding the relationship between TA and survey. The majority of respondents reported that they believe the TA programs are worthwhile and have a positive impact on facility quality of care. However, they varied in their opinions regarding which facilities should be targeted to receive technical assistance. Some consumer advocates said TA programs should focus primarily on small independent facilities that have fewer of their own resources from which to draw. Other stakeholders thought TA programs should either be mandatory for all providers or should focus primarily on poor performers. Strong, but by no means unanimous, opinions were expressed about whether states should maintain separation between their TA programs and their LTC survey and certification process. States that had preserved that separation felt strongly that it is critical to the fundamental purpose of TA--i.e., to help facilities improve the care they deliver. Stakeholders from both the state survey agencies and the TA programs holding this view emphasized that any blurring of the lines between survey and TA could cause providers to become skeptical about confidentiality, and to fear that information shared during TA sessions will be reported to surveyors. They felt that this lack of confidentiality has the potential to chill the relationship between technical assistance staff and facilities, resulting in a loss of candor on the part of facilities and, as a result, lost opportunities for TA assistance. In contrast, most program staff and many providers that we talked to in states with closely tied TA/survey programs recommended that TA staff also function as surveyors for reasons that are discussed in section 3.2, namely that the association with survey causes TA staff to have greater authority, more regulatory knowledge, and therefore a better ability to effect positive changes in resident care. In several states, respondents, representing both TA programs and facilities, stressed how important the quality and personality of TA staff is to the success of their efforts. To be effective, it was generally agreed, staff members should be experienced in long-term care and sufficiently flexible to work collaboratively with facility staff. It was also agreed that the standards used and the training given to TA staff must be consistent to avoid subjective consulting across facilities. 7.2 Other Quality Improvement InitiativesAdministrators of quality improvement programs in study states also offered some specific advice for state officials interested in developing other QI initiatives: Awards and Recognition Programs and Best Practice Initiatives. Participants thought it important to ensure that there is a consumer advocate position on the selection panel, and that this position is well defined so it does not default to "an industry representative who has a relative in a nursing home." They also recommended that the selection panel visit any facility nominated for an award, to validate nomination criteria and make sure the facility is in fact "doing something special" and not merely meeting minimum criteria. Stakeholders said it was important that the selection process be seen as objective--so that the award, in turn, is seen as truly recognizing outstanding quality. Stakeholders recommended that consideration be given to the criteria used to select facilities for awards. States advised caution about setting criteria too low or evaluating facilities over too short a period to ascertain whether the facilities chosen were maintaining good practice on a consistent basis. This is important to avoid the inevitable bad publicity and diminished consumer trust that result when facilities singled out for recognition later experience quality problems. Training Initiatives. Several stakeholders advocated that the most effective training programs were those that included both interpretation of regulations and practical examples of integration of care principles. Some also recommended joint training for providers and LTC surveyors. This admittedly leads to some discomfort in both groups, but it provides an effective medium for dialogue between providers and surveyors, has the potential to promote greater understanding and cooperation, and ensures that both groups receive the same information. This, in turn, decreases the problem of different interpretations of the guidance offered. With respect to education more generally, some participants noted the need to educate (a) the public about realistic expectations regarding nursing home care outcomes and (b) facilities to better manage the expectations of patients and families. Public Reporting Programs. Comments by some stakeholders suggest skepticism about consumer use of public report cards on nursing home quality. Nonetheless, in states that invest in public reporting, it became apparent during our discussions that a balance must be struck between providing enough information to consumers to assist them in making more informed decisions and overloading them with information and data that becomes too cumbersome to decipher. One solution recommended by several states is to develop a scoring system that incorporates multiple quality measures (e.g., survey and deficiency information and/or quality indicators). The advantage of such a system is that it reduces information overload and is easy for the consumer to understand. States caution, however, that the accuracy of these scoring systems as predicators of real quality is subject to considerable dispute and has not been empirically validated. States also advised caution regarding the potential negative impact on access, if facilities begin turning away heavier care residents patients because they fear their "consumer report cards" will be adversely affected by scoring systems that do not take sufficient account of facility differences in types of patients (and their differing care needs). 8.0 Suggestions from Study States to the Federal GovernmentDuring the case studies we asked stakeholders if there were any suggestions they wished to offer the Federal Government with respect to nursing home quality improvement. The comments we received applied to perceived federally imposed barriers to state-initiated quality improvement programs, and to federal policies related to regulation, staffing, and quality. In general, the states said they wanted to improve their relationships with the Federal Government. Officials in one state described the relationship between CMS and the state as "hostile." Providers in that state were especially upset by their belief that a deficiency-free state survey often triggered a federal survey. They encouraged the Federal Government to implement a policy that rewards good nursing homes with less frequent surveys and to focus resources on poorly performing facilities. Officials in another state said the Federal Government should be more flexible in allowing states to be innovative and to make their own attempts to improve quality. Stakeholders across states expressed a desire to either implement or expand technical assistance programs or other quality improvement initiatives--but believe that federal funds for such initiatives needs to be expanded. 8.1 Federal Program ProvisionsCMS Public Reporting Initiative and Quality Improvement Organization (QIO) InvolvementWashington State was a pilot state for the recent federal piloting of national public reporting of quality measures (QMs). Respondents there had very mixed opinions of the QM public reporting, though general agreement among those who commented was that "quality indicator" rather than "quality measure" was a more accurate descriptor for the measures, since those interviewed did not believe that the QMs are the only aspect of quality that should be considered when making judgments about facility quality. Some consumers in Washington were also skeptical of the QM initiative, saying that the QMs are too clinical and that they did not believe there was good correlation between performance on QMs and "real quality." Consumers also argued that the Federal Government should do more to assure that there is more consumer (resident) representation on federal quality initiatives such as the QM and QIO projects. Officials in another state believed that information on CMS Nursing Home Compare website was too general and that the website needed to post more details to be really helpful to states. They thought it would be preferable to post all CHSRA QIs for each nursing home. Program staff in one state thought that CMS should post five years of survey and complaint data plus selected QIs. Respondents were also concerned about timeliness of data, since it heavily impacts the value of the posted information to consumers. Regarding the new QIO initiative, many respondents from state survey agencies believe that the QIO program was an untapped resource that could be used, along with the state's survey agency, to work together and bring about changes in facility practices necessary to improve quality. One state believed CMS would be better served to award that responsibility (and associated funding) directly to the states. Some respondents suggested that the role of the QIO as an "improver" may be undermined by the QIO's required function as an "enforcer." Officials in another state were more concerned about the QIO's lack of experience with nursing facilities. OverregulationMany respondents felt that the current level of federal regulation is too demanding, although facility representatives generally felt that the state was even more demanding than the Federal Government in its expectations for high quality performance. Others were less concerned about the amount of oversight and more concerned about a need for more understandable regulations. Finally, one state's for-profit providers indicated that the federal regional offices should be doing a more diligent job overseeing the local state field offices to make sure they were doing their jobs fairly. StaffingStakeholders were universally concerned about staff turnover and the related issues of maintaining adequate staffing in facilities. All complained of staffing shortages, high turnover, lack of mid-level staff with management skills, and pervasive use of contract staff. One state's consumer representative said that while she was not opposed to new quality improvement programs, the main issues at hand concerned inadequate staffing of the programs currently operating. Some stakeholders, particularly consumers, believe that the best thing the Federal Government can do to improve nursing home quality is to do "whatever it takes to improve staffing." On the other hand, some providers expressed concern that requiring minimum staffing ratios would not be appropriate, particularly if there were not significant reimbursement increases to pay for the higher staffing levels. There is concern about the ability to staff at the required level, given the nursing shortages that exist in many parts of the country, and also concern about how to account for differences in facility case mix in determining the required minimum staffing level for each facility. 8.2 Other SuggestionsA variety of other suggestions comments were also directed to the Federal Government.
32. Note that CMS is currently working on an updated RAI manual and clarified instructions for coding the MDS. 9.0 ConclusionsThe backbone of the nation's system for monitoring nursing home quality of care is the LTC survey and certification process, which focuses on facility compliance with the regulations governing Medicare and Medicaid certification. This regulatory focus sharply limits the amount and types of consultative advice LTC surveyors can provide, as reflected in Section 4018 of the State Operations Manual: "It is not the surveyor's job to examine the facility's policies and procedures to determine or speculate on the root cause of deficiencies, or to sift through various alternatives to prescribe one acceptable remedy."33 Survey and certification staff are directed not to assist facilities with in-depth problem solving on ways of improving the quality of care delivered. They are allowed to disseminate information that may be of assistance to the facility in meeting long-term care requirements, but they do not provide training to nursing home staff on quality-related issues.34 This limited focus, combined with continuing concerns about nursing home quality, has led some states to supplement their quality assurance standards with consultative, collaborative programs that directly address quality improvement. The goal of the study reported here is to examine these state-initiated quality improvement efforts and, more specifically, to identify their characteristics and look for information that might be helpful to other states considering such initiatives. We focused on seven states with quality improvement programs: Florida, Iowa, Maryland, Maine, Missouri, Texas, and Washington. For each of these states, we collected detailed information on their quality improvement programs through both in-person and telephone discussions with stakeholders.
9.1 Technical Assistance ProgramsWhile we cannot systematically evaluate the effectiveness of technical assistance programs in improving quality of care, feedback from providers in the states we visited indicates a need for this type of program. All discussants agreed that technical assistance programs fill an important gap, and the majority of stakeholders we talked to, including officials from state survey agencies, provider representatives, and consumer advocates, believe these programs have had a positive impact on improving nursing home quality. It is also abundantly clear that, in all the states we visited, the technical assistance staff have been able to establish a more collaborative, less adversarial relationship with nursing facilities than is typical for surveyors. Many nursing facility staff seem to value the opportunity to have an open dialogue with technical assistance staff about problems and issues in residents' care, to obtain information on good clinical care practices, and to receive training and feedback on how they can improve their care processes. There are, however, some providers who seem to misunderstand TA programs that do not focus on regulatory issues or survey performance. Many facilities consider this a disadvantage, because achieving good survey outcomes is an important goal for them. Some facilities, indeed, are primarily interested in receiving advice on survey preparation. These facilities generally are not receptive to the types of quality improvement oriented assistance provided as part of the technical assistance programs in the majority of states we studied. As discussed below, however, there are also potential disadvantages in having a TA program that is closely tied to the survey process. The enforcement process does not appear to have been compromised in states with technical assistance programs. In some states this is because technical assistance and survey activities are separated from one another. The technical assistance programs in Maine, Maryland, Missouri, and Texas, for example, do not directly deal with compliance issues. In the states where the two functions are not as distinctly separated, Florida and Washington, the technical assistance programs have more of a regulatory focus and direct consultation on care processes is typically not provided. We heard a few reports of problems when advice from the TA staff conflicted with what the facility heard from surveyors, but these incidents appeared to be isolated. TA programs are clearly able to provide a constructive complement to the enforcement-related survey and certification activities. To date, only Missouri has formally assessed the effectiveness of their program. Their analysis has shown improvements, since program implementation, in the majority of quality indicators the state has selected for comparative measurement. In coming years, we expect additional analyses of program effectiveness. Such analyses may allow more definitive conclusions to be drawn regarding which types of TA programs are most successful in improving quality. In spite of considerable differences across states in the design and goals of their technical assistance programs, several common issues emerged that states planning technical assistance programs need to consider. Separation Between Technical Assistance Program and Survey ProcessThe typical reaction of nursing facility staff is to distrust technical assistance programs, particularly if they are run by the state survey agency or staffed by former or current surveyors. Many administrators want to avoid having surveyors in the facility any more frequently than is required by law. It takes time to educate facility staff about the potential benefits of technical assistance programs, and a major component of this educational process involves convincing facility staff that it is "safe" to have an open discussion with technical assistance staff and that results of technical assistance visits will not lead to survey deficiencies. Separating the technical assistance function from the survey process almost certainly helps achieve this purpose. The degree of separation between technical assistance and survey staff varied across states. Missouri and Maryland has the greatest separation. In Missouri, there is little interaction between the state's technical assistance staff, who are employed by the University of Missouri, and the survey agency. This separation seems to facilitate the emphasis of these programs on providing consultation to facility staff, including reviewing care plans for individual residents and providing training to staff. Technical assistance staff in Missouri deliberately avoid enforcement and regulatory issues. LTC survey staff, in turn, avoid any consultative role. Acceptance of Missouri's program by nursing facilities was reportedly slowed because, when the program started, it was more closely linked to the survey process. In Maryland, the state's technical assistance nurses report only the most extreme quality of care violations to the state survey agency. When technical assistance staff identifies routine violations, they bring such violations to the attention of the nursing home staff, require a plan of correction, and provide ongoing compliance monitoring. The state believes this level of separation is necessary in order to get providers to accept the technical assistance program. In states like Washington, where the distinction between technical assistance staff and the survey agency is not clear, it is likely that this causes some distrust of the technical assistance staff by nursing home providers, resulting in a reluctance to have an open discussion with technical assistance staff about quality improvement issues. We were not able to evaluate whether this affects program effectiveness, but comments from providers suggest that this close association between TA and survey staff can present real problems. Making a Choice between a Focus on Directly Improving Care Practices versus Improving Regulatory ComplianceThe principal reasons for selecting either an approach that emphasizes nursing home care practices or regulatory compliance appear to be primarily related to the stance of the state and the availability of federal funding for programs based in LTC regulation. Particularly in Washington State, there is a belief that the monitoring and enforcement of federal requirements for facilities can and does result in higher quality of care delivery. It is clear that many nursing facilities value technical assistance that is focused on improving survey outcomes, and that some value this type of assistance more than technical assistance directly focused on improved quality of care. There may be greater potential for conflict-of-interest for the programs with a regulatory focus, with TA staff who often work as part of the state survey agency, providing advice on issues related to regulatory compliance, but there are no data that permit determination of which type of approach is more effective in improving quality. It is also the case that in states where technical assistance programs have a primarily regulatory focus, the distinction between technical assistance and LTC survey tends to become blurred. In Florida and Washington, for example, technical assistance staff occasionally act as surveyors, sometimes having to clarify with facilities as to which role they are playing on a particular day. This would seem to have an obvious impact on the type of information shared between facility and technical assistance staff, which can be expected to mute the effectiveness of any technical assistance whose intended focus is quality improvement outside the realm of regulation. Importance of TA Program StaffingAcross all the study states, TA staff tend to be experienced and highly trained. Florida's quality monitors were initially recruited from the best surveyors in the state. Washington's QANs are all masters-prepared nurses. Most of Missouri's technical assistance staff have advanced nursing degrees and many have been personally recruited by the director of the technical assistance program. It is noteworthy that, in all the study states, the technical assistance staff tend to be more experienced than most of the surveyors. This gives them the clinical knowledge they need to address the variety of topics that may be covered during a technical assistance visit. In addition to clinical experience, the personality of technical assistance staff was considered important to the success of a quality improvement effort. Our discussants said that technical assistance staff need to be good teachers, good communicators, and good listeners. They need a personality that allows them to build trust with facilities and enables them to encourage facilities to be active participants in the technical assistance program. These "soft skills" could well be as important to technical assistance staff success as their clinical background. States varied with respect to whether technical assistance staff had survey experience, and we could not draw any conclusions about the importance of this type of experience. On the one hand, we heard reports that it may be difficult for surveyors to change from emphasizing enforcement issues to focusing on nursing home care practices. On the other hand, experienced surveyors may have insights from their experience as to best practices observed at other facilities that they can share. Having survey experience was clearly important for technical assistance programs that have a regulatory focus. The Trade-Off Between Regulatory and Care Practice FocusThe technical assistance programs in Florida and Washington, which emphasized regulatory compliance issues more than the programs in other states, provided only a limited amount of direct consultation to nursing homes. Florida's quality monitors are deliberately careful to keep suggestions very general, forcing the facility to select the processes they feel are most appropriate to the needs of their residents. In Washington, technical assistance staff advise facilities to network with one another, but they avoid telling facilities how to fix problems. Reasons for the limited consultation provided in these states include (1) avoiding the danger of facilities being cited for doing something technical assistance staff told them to do; (2) limiting the potential liability of the technical assistance program for any advice they may give; (3) Federal restrictions on the types of consultation that can be provided as part of the survey and certification process; and (4) in Washington's case, preserving the perception that they are not providing "technical assistance" in order to maintain eligibility for federal funding. In Maine, Missouri, and Texas, where the explicit intent is provision of direct consultation with facilities that is unrelated to regulatory issues, technical assistance staff appear to be comfortable sharing advice with facilities on how to treat particular conditions and individual residents. The Maine technical assistance nurse actually drafts care plans for inclusion in the medical record. Missouri technical assistance staff bring along many resource materials to the facilities they visit and provide guidance on a variety of topics. Texas technical assistance staff disseminate evidence-based best practice guidelines. Stakeholders in these states told us they greatly value the types of direct consultation provided under these technical assistance programs. Trade-off of Mandatory Program ParticipationIn most study states, facility participation in technical assistance programs is mandatory. Participation in the technical assistance programs in Maine and Missouri, however, is voluntary. About 45 percent of nursing facilities received on-site consultation from Missouri's technical assistance program. Detailed facility statistics are not available for the Maine program since they track interventions by resident rather than by facility, but it is believed that a majority of the state's 126 nursing facilities have participated. Voluntary programs allow facilities that do not want technical assistance to opt out and not receive this assistance. This runs the obvious danger that the facilities most in need of help may not receive it. Study discussants suggested that facilities with the worst quality do not participate, in part because they either do not understand the program or do not have the systems in place to benefit from it. This is certainly a plausible result of voluntary participation. The state survey agency in Missouri did not contradict this position, but was not troubled by such a possibility, arguing that the problems at the facilities with the most severe quality issues should most properly be addressed through the enforcement process rather than through TA. On the other hand, even for states with mandatory technical assistance programs, it is likely that some facilities do not benefit from the programs--either because they are not willing or able to use advice received during the technical assistance visit to make changes to care processes. Some discussants believe that high staff turnover has resulted in facility staff actually having less contact with technical assistant staff. It is not clear that focusing on poor performing facilities would maximize the impact of technical assistance programs, given that these facilities may be too overwhelmed by the tasks involved in providing basic care to be able to undertake new quality improvement initiatives. The Value of Focusing TA Visits on Quality IndicatorsMaryland, Missouri, and Washington all incorporate quality indicators into their protocols. These States' use of quality indicators includes: (1) a means of targeting clinical areas of focus (Washington and Missouri); (2) a foundation for measuring how well both facilities and the technical assistance program are performing (Maryland and Missouri); and (3) a basis for facility improvement plans that can then be reviewed as part of the TA visit (Maryland). The Need to Make Evaluation Part of the Program DesignThere have been few systematic evaluations of the effectiveness of state technical assistance programs, and the designs of the current technical assistance initiatives--even when they have been in operation long enough to permit evaluation--will make it difficult to estimate how well the programs work. Of particular concern from an evaluation perspective is the simultaneous statewide implementation of several quality improvement programs. This is understandable, given the perceived urgent need to improve nursing home quality. However, a strategy that concurrently implements multiple interventions makes it virtually impossible to measure the effectiveness of any particular type of technical assistance. States planning to implement quality improvement programs should consider the increasing importance of the need to evaluate these programs given the current fiscal environment. Federal Funding for Quality Improvement ProgramsFederal funding is not generally available for programs that have a consultative or quality improvement focus. The study states make limited use of federal funds for their technical assistance programs, typically funding their programs from state general revenue funds, sometimes supplemented by the state portion of Civil Monetary Penalty (CMP) awards and/or penalties or fees levied on facilities. Some states explained that there were "too many strings attached" to use federal funding for these TA activities. 9.2 Other State Quality Improvement InitiativesOther quality improvement programs in the study states fall mostly into one of four categories--training programs, programs that provide recognition to high-performing facilities, best practices programs, and public reporting programs. The same staff are generally responsible for both the TA and these other programs (with the exception of public reporting programs), and the two are often operationally indistinguishable. The effectiveness of these programs has not been explored, and measuring their impact on quality of care would be difficult if not impossible. But feedback from provider and consumer groups indicates that they have generally been well received and are viewed positively, even if they are not perceived as producing large changes in quality. TrainingAlmost all states had some type of formal training as part of their quality improvement programs. In general, these training sessions have been well attended and feedback has been positive. It is not possible to determine whether these training programs have led to quality improvements, although there is some anecdotal evidence of practice changes that were made following training sessions. The experiences of states that have conducted joint surveyor-provider training programs is mixed. Having both surveyors and providers at the same training session often inhibits discussion, and there is often resistance from both sides. Such sessions do, however, ensure that both providers and surveyors receive the same information and may ultimately help to improve the surveyor-provider relationship, leading to better communication during the survey process. With respect to training programs, some participants noted the need to educate the public about realistic expectations regarding nursing home care outcomes and the need for facility training to help them to manage better the expectations of patients and families. Best PracticesOur research team noted a great deal of variation in what the study states described as best practices. Programs varied in how best practices were defined, where they originated, and how they were positioned among the state's other quality improvement programs. Some states defined best practice simply as an innovative idea originating at the facility level that was seen as potentially valuable to other facilities. For example, Iowa posts on its website innovative best practices deemed to be among the best in the state. Other states define best practices based on expert-derived, clinical protocols that should be adopted by facilities so as to raise the standards of practice. This is the approach used in Maryland, Texas and Missouri. Facility RecognitionFlorida and Iowa have developed and initiated reward and recognition programs as part of their quality improvement efforts. The goal of these programs is to recognize facilities doing exemplary work. These programs received positive feedback from both providers and consumer advocates. Providers view them as tools for combating the negative stereotype of nursing homes so often presented to the public. Consumer advocates present them as potentially useful sources of information for elders and their families making long-term care decisions. There is concern, however, that these types of programs are focused on facilities that already deliver quality care, and may divert state attention from the facilities with the quality problems. Public ReportingThere was some concern about whether public reporting is useful as consumer information or as a marketing tool used by nursing homes. However, given the increasing use of this type of information, all discussants agreed that public reporting programs must strike a balance between providing information to consumers to assist them in making more informed decisions and not overloading them with information and data too complicated for them to use. Many discussants expressed concern that publicly reported data needed to be timely, valid, and sufficiently risk adjusted to provide meaningful information. In addition, provider groups expressed strong opposition to posting survey results that are under appeal. Given that the appeals process can take years to reach a final resolution, not posting results until appeals are resolved would result in data that are too out-dated to be useful for consumers needing to make placement decisions. Research is needed to understand the extent to which (a) public reporting systems are used by consumers to guide nursing home placement decisions, and (b) public reporting of information on facility quality actually leads to quality improvements. ReferencesCenter for Medicare and Medicaid Services. Study of Private Accreditation (Deeming) of Nursing Homes, Regulatory Incentives and Non-Regulatory Incentives, and Effectiveness of the Survey and Certification System, Report To Congress, 1998. General Accounting Office. California Nursing Homes: Care Problems Persist Despite Federal and State Oversight. GAO-HEHS-98-202. Washington, DC: GAO, 1998. General Accounting Office. Nursing Homes: Complaint Investigation Processes Often Inadequate to Protect Residents. GAO-HEHS-99-80. Washington, DC: GAO, 1999. General Accounting Office. Nursing Homes: Quality of Care More Related to Staffing than Spending. GAO/HEHS-02-431R Washington, DC: GAO, 2002. General Accounting Office. Nursing Homes: Sustained Efforts Are Essential to Realize Potential of the Quality Initiatives. GAO/HEHS-00-197. Washington, DC: GAO, 2000. Institute of Medicine. Takeuchi, J., Burke, R., and McGeary, M., eds. Improving the Quality of Care in Nursing Homes. Washington, DC: National Academy Press, 1986. Massoud, MRF. 2001. Advances in Quality Improvement: Principles and Framework. QA Brief--The Quality Assurance Project's Information Outlet. Spring, 9:1. Minority Staff, Special Investigations Division, Committee on Government Reform, U.S. House of Representatives. Abuse of Residents Is a Major Problem in U.S. Nursing Homes, July 2001. Office of the Inspector General. Nursing Home Survey and Certification: Overall Capacity, OEI-02-98-00330. Washington, DC: OIG, 1999(a). Office of the Inspector General. Quality of Care in Nursing Homes, An Overview, OEI-02-98-00060. Washington, DC: OIG, 1999(b). Office of the Inspector General. Nursing Home Survey and Certification: Deficiency Trends, OEI-02-98-00331. Washington, DC: OIG, 1999(c). Popejoy, L.L., Rantz, M.J., Conn, V., Wipke-Tevis, D., Grando, V., & Porter, R. (2000). Improving quality of care in nursing facilities: The gerontological clinical nurse specialist as a research nurse and consultant. Journal of Gerontological Nursing, 26(4), 6-13. Rantz MJ, Popejoy L, Petroski GF, Madsen RW, Mehr DR, Zygart-Stauffacher M, Hicks LL, Grando V, Wipke-Tevis DD, Bostick J, Porter R, Conn VS, Maas M (2001). "Randomized clinical trial of a quality improvement intervention in nursing homes. The Gerontologist 41(4), 525-538. Shewart, W.A, Economic Control of Quality of Manufactured Product, ASQC, Van Nostrand, New York, NY, 1980. State of Florida, Senate Staff Analysis and Economic Impact Statement, Bill CS/CS/CS/SB 1202 Long Term Care.http://www.leg.state.fl.us/data/session/2001/Senate/bills/analysis/pdf/2001s1202.ap.pdf. Walshe K. (2001). Regulating U.S. nursing homes: Are we learning from experience? Health Affairs 29(6), 128-144. TABLE 1. Description of State-Initiated Technical Assistance Programs
TABLE 2. Non-TA Quality Improvement Programs, by State
AppendixesAppendix A. State ReportsFloridaOverview of the Florida VisitThis report describes our review of the nursing home quality improvement programs initiated by the State of Florida. It begins with background information on the programs and how the visit and discussions were structured, and continues with a brief account of the origin and rationale for the programs. A description of the programs follows, along with the research team's findings. These findings are based on discussions with state employees, nursing facility respondents, and consumer representatives) regarding the perceived strengths and weaknesses of the programs. A discussion of the impact these programs have had on the quality of life and quality of care of Florida's nursing home residents follows. The report concludes with suggestions from program designers and participants to other states that might want to implement similar programs, a discussion of the sustainability of the various programs, and the respondents' opinions on the role of the Federal Government in quality improvement in nursing facilities. A Brief Description of Florida's Nursing Home IndustryIn order to compare Florida's nursing home industry with the other study states, we present some descriptive characteristics. There are 734 facilities in Florida (AHCA web site) with 69,122 residents reported as of Spring 2001. The average number of beds per facility is 114, which is slightly higher than the national average of 108. The median occupancy rate per facility is 86.7 percent as compared to the national rate of 95.1 percent. The percentage of for-profit homes in Florida is higher than other states, with 76 percent of homes operating for profit versus 65 percent nationally. The not-for profit-homes are lower at 23 percent vs. the national average of 28 percent. There are also fewer government-operated (2 percent vs. 7 percent) homes. The majority of homes operate as part of a chain (70 percent vs. the national average of 55 percent) and 10 percent of facilities are hospital-based, which is slightly less than the national average of 12 percent. The majority of homes are dually certified for Medicare and Medicaid (88 percent) as compared to the national average of 80 percent. There are approximately 2400 assisted living facilities and 1100 home heath agencies. (FPECA) (p. 17). Impetus for Florida's Quality Improvement ProgramsFlorida's quality improvement programs are the result of legislation passed in 1999, 2000 and 2001. Prior to the passage of the legislation, respondents explained that the atmosphere in the state was unsettled with a number of issues facing nursing home providers, regulators and consumers. There was increasing concern with the quality of care in nursing facilities and how quality was to be defined and communicated to consumers. In 1999, HB 1971 was passed, which included provisions for a technical assistance program, a quality recognition program, development of a website to post facility information for consumers, training programs and medical director standards. In 2000 a minor bill was passed that revised the measures that would be posted on the website and modified the types of documentation required for the discharge and transfer of residents. At the same time these actions were taken, there was increasing concern about rising rates of litigation against nursing facilities and the effects of litigation on facilities' financial stability. Lawsuits had become common, affecting facilities regardless of their reputation for high or low quality care. Facilities were reportedly paying 500-fold increases in insurance rates while other facilities were unable to secure any insurance. During discussions with agency staff, it was stated that Florida ranked third in the nation for skilled nursing facility bankruptcies (behind Texas and California) and that Florida had 10 percent of the country's nursing home beds but 50 percent of the nursing home litigation. In response to these concerns, lawmakers created a 19-member Task Force to study the affordability and availability of long term care in Florida. The group was mandated to study and make recommendations on a number of issues pertaining to long-term care. Those specific to quality of care were the following:
The Florida Policy Exchange Center on Aging at the University of South Florida (FPECA) was named to provide staff support to the Task Force. FPECA's research indicated that the number of lawsuits against Florida nursing homes had in fact dramatically increased, that insurance rates had been going up, that insurance companies were writing fewer policies and that consumers were complaining of poor quality of care and violation of residents' rights. They studied risk management in hospitals and concluded that the institution of an internal risk management program in nursing facilities "could be an appropriate step…to bring about a comprehensive quality care approach. Such a step could both encourage improved quality of care and remedy the prevailing litigious climate in the industry."2 In a 700-page report, released in February 2001, the Task Force presented their findings on the major task areas including options for improving nursing home quality. SB 1202 was signed into law in May 2001 based in part on the findings from the Task Force. As part of the compromise between consumer advocates and industry representatives, consumers agreed to tort reform in the form of limiting the amount of settlements against long term care facilities on the condition that this was partnered with increased oversight on quality. The quality improvement legislation contained the following components:
The legislation was passed on May 15, 2001 and enacted immediately. There was no period for facilities to prepare or for the State to develop interpretations of the bill.
Overall Intent/Vision for Florida's Quality Improvement ProgramsThe vision of Florida's quality improvement programs, as expressed upon the passage of SB 1202, was to bring about an improvement in quality of care through a combination of risk management and internal quality assurance along with increased oversight and guidance to facilities. With liability insurance either unaffordable or not available, lawsuits affecting virtually all the long term entities in the state, and bankruptcies affecting 22 percent of skilled facilities, measures to deal with both the litigation crisis and quality of care problems in facilities were believed necessary to ensure the viability of the long term care industry in the state. FPECA staff we spoke with expressed the idea that the Task Force sought to "marry" the issues of quality of care in nursing homes, liability and insurance and home and community-based care. During our visit, there was much discussion among stakeholders regarding the relationship between quality improvement and risk management, and the relative importance of each component. Providers stated that the quality of a nursing home had little effect on the number of lawsuits brought against it. Consumer advocates expressed the opinion that it was "embarrassing" to think that controlling litigation would bring about quality improvement. However, most participants expressed agreement with the Task Force that it was not appropriate to address the liability crisis separately from quality reforms. Description of Quality Improvement Programs in FloridaFunding: Quality of Long-Term Care Facility Improvement Trust FundThe Quality of Care monitor program is funded through a Quality of Long-Term Care Facility Improvement Trust Fund that, in 2001, was created within the state's Agency for Health Care Administration. The trust fund supports activities and programs directly related to the care of nursing home and assisted living facility residents, and is funded through a combination of general revenues and 50 percent of any punitive damages awarded as part of a lawsuit against nursing homes or related health care facilities (Florida law 400.0238). Monies in the fund come from a percentage of punitive awards in nursing home and ALF court awards, gifts, endowments and other legal charitable contributions, along with specific appropriations by the Legislature. According to the legislation that created the trust fund, expenditures from the trust fund can be made for direct support of the following:
For FY 2001-2003, the total cost of the state's Quality Monitoring program is about $1.65 million--this includes $1,395,911 for the quality monitors and $261,000 for other expenses. The legislation authorizing the quality monitor program also increased licensing fees for facilities (from $35 to $50 per bed), and this increase covered part of the costs of the TA program.3 Costs for other Florida quality improvement programs that were funded under Senate Bill 1202 (2001) are as follows: nursing home risk management and quality assurance program: $2.1 million in FY 2001-02 and $1.54 million in FY 2002-03. (This includes costs of about $450,000 for data system development) and staff costs; Nursing Home Care Alzheimer's training: $10.5 million in FY 2001-02 and $6.8 million in FY 2002-03; surveyor training: $66,000 (in both FY 2001-02 and FY 2002-03). The risk management program is paid for entirely by state funds, but federal funds cover more than 50 percent of the funding for the state's Alzheimer's Training Program, under which dementia-specific training is provided to staff who care for residents with Alzheimer's Disease.4
Aspects of Florida's Quality Improvement Programs Noted to Work WellSome provider representatives asserted that the Quality Monitors, Gold Seal and Risk Management are programs that have impacted the quality of care in their facilities. Although opinion on the value of the Quality Monitor program was mixed, some provider representatives expressed that they found the visits to be very helpful, describing them as providing objective non-punitive advice. Providers also appreciate the Quality Monitors sharing information on best practices, recommending educational materials and offering interpretation and clarification of state and Federal rules and regulations. The Gold Seal program was seen by some as a good marketing device that potentially can decrease the cost of liability insurance and drive up revenues. Consumer advocates praised the fact that it requires a financial audit. Participants reported that the Risk Management requirement had forced them to investigate incidents and accidents in greater detail, examine their facility processes for flawed practices, and make changes with the goal to prevent future problems. Educational training programs including the Teaching Nursing Homes and Alzheimer Training were described as useful by several of the provider representatives with whom we spoke. Providers felt that the Alzheimer Training was most useful for non-nursing staff and for facilities that did not have a designated ADRD unit. The approval process for trainers and curricula for the Alzheimer Training program is considered innovative. Each submitted curricula is reviewed by a doctoral-level staff member at the Florida Policy Exchange Center on Aging at the University of South Florida. Many of the curricula as initially submitted, contained incorrect or out-of-date information and had to be returned to facilities for correction and resubmission. Although providers were aware of the compact disc developed for LPNs on Alzheimer's disease as part of the Teaching Nursing Homes program, and were pleased that it would be web disseminated, most indicated that they had not personally reviewed it. Some discussion participants approved of the state's web-based Nursing Home Guide, particularly the star assessment system. FAHA staff and providers expressed that the star system does a reasonable job with some expressing the opinion that it does a better job of evaluating quality than the CMS Nursing Home Compare site. Discussants also commented on the mandated staffing increases, noting that the gradual mandated nursing assistant staffing increases were seen as more reasonable than one large increase. Advocates were pleased that SB1202 created language to link facilities in large chains so that a staffing problem in one facility of a chain is viewed by the State as non-compliance across all the homes in the chain. Aspects of Florida's Quality Improvement Programs Noted to be Less SuccessfulAlthough some discussion participants praised the Quality Monitoring program, consumer advocates voiced some concerns, primarily because of the changes that were made to the original role and responsibilities as laid out in HB 1971 in 1999. The program as initially enacted was seen as separate from the survey agency and allowed the monitors to focus on the more problematic facilities. In SB1202, the quality monitors' roles and responsibilities were expanded. It required the Quality Monitors to provide quarterly visits to each facility in his/her region, oversee the risk management program, verify that facilities were meeting the minimum staffing requirements and perform various surveyor activities as needed. Quality monitors are now responsible for monitoring facilities that were closing or in immediate jeopardy and provide orientation for new surveyors. By taking on surveyor tasks, the separation between quality monitoring and enforcement became less distinct. Provider association members reported that since the Quality Monitors are seen more as part of the risk management effort now, providers rarely think anymore about how they can use them for quality improvement. Consumer advocates were concerned that the close ties between Quality Monitors and surveyors would lead to one group putting pressure on the other so that the information they presented about facilities was consistent between them. For example, a poor survey outcome could lead to the conclusion that the Quality Monitor was not providing effective oversight. There was some concern expressed that Quality Monitors hired as a result of SB 1202 were not as qualified as the former surveyors hired in the first round, and that there was great variability in the quality of quality monitoring depending on region of the state. Providers noted that often they were asked to provide information for the Quality Monitors who did not necessarily have a background in long term care. They also stated that a problem existed with inconsistency between information being disseminated by Quality Monitors and surveyors. Some providers complained that visits were not occurring on a quarterly basis because of Quality Monitors being overwhelmed and the position experiencing high turnover rates. They also noted that often a survey followed a quality monitoring visit, focusing on the same issues that the monitor had raised, causing them to question whether the Quality Monitors were maintaining confidentiality of the visits. Consumer advocates objected to the promotion of the best surveyors out of the enforcement agency, saying it weakened survey. They also stated that they did not agree that taxpayer funds should be used to provide advice to multi-facility chains on how to deliver care, likening it to the government providing training to Fed-Ex on how to deliver packages on time. They agreed that small, independent facilities often needed and should be entitled to such support, but it made more sense to shut down large for-profit chains if they provided poor quality care to residents. Concern was also expressed that because Quality Monitors must now oversee the risk management programs, visits are no longer always unannounced, since the Quality Monitor must meet with the facility's designated risk manager. Respondents were critical of the Gold Seal program because the strict criteria eliminated the majority of facilities. The expense of a financial audit, which is required, was also a negative. Providers noted that there was not much incentive to seek a Gold Seal, as there was no change to the survey cycle, no immunity from lawsuits and no change in reimbursement. Although some facilities praised the risk management process as teaching them how to critically evaluate their protocols, the reporting of adverse incidents and the confusion around the reporting requirements has put providers in a difficult situation. Facilities have been over reporting adverse incidents because they have trouble identifying incidents that are in their control and because the stakes for not reporting are so high. The failure to report an adverse incident to the survey agency can result in a G-level deficiency. A G-level deficiency citation results in placement on the Watch list. Two G-level deficiency citations may result in a six-month survey cycle and imposition of fines. Reporting of adverse incidents was intended to distinguish better performing facilities from problem facilities, thus encouraging insurance companies to come back into the state. In part because of the over-reporting issue, however, no progress has been made in improving the insurance situation. Participants also noted that no credentials or qualifications were mandated for the facility risk manager. Requiring credentialing was seen as one way to improve the program. Both the Nursing Home Watch List and Nursing Home Guide are based on survey outcomes and were thus criticized because of the recognized inconsistency of survey results. Participants noted that information in both areas was often not available in a timely manner. The website star system is based on 45 months of data and participants noted that, "a lot can happen in 45 months." Consumer advocates did not agree with the star system, maintaining that giving the worst facilities in the state even a one-star rating was misleading. They also did not agree with the agency's practice of not posting information until appeals had been resolved. Advocates also recommended that the website should contain information on lawsuits and fines. Providers also noted that Florida consumers now have access to three types of sites with nursing home quality of care information--the CMS site, the proprietary sites and the AHCA site. Since information varies from site to site, they use different ratings, and show different levels of compliance, they question how this helps consumers. Providers were very concerned that the mandated increase in nurse aide staffing to 2.9 ppd (due in January 2004) is going to be virtually impossible to attain. They are concerned that it will force facilities to compete with one another by offering bonuses and incentives. There was disagreement as to the adequacy of the workforce needed to meet the future requirements. Consumer advocates stated that there were plenty of nurse aides available in the state, with 250,000 on the registry and 10,000 new grads each year. They saw nurse aide shortages as the result of the poor conditions, benefit and pay provided by facilities and stated that improving working conditions and giving nurse aides 40 hour work weeks would go a long way to remedying the situation. Provider representatives, however, said that there was not an adequate supply to meet the demand "without significant wage pressure." Two-thirds of Florida's nursing homes are paid for by Medicaid and they will not be able to increase wages to engage in competition for employees. Provider representatives also noted that they would like the State to relax the requirement that facilities self-impose an admission moratorium when unable to meet the staffing minimums. They would also like to see the staffing requirement relaxed for smaller facilities. Facilities are being forced to use temporary agency staff to meet the requirements. The cost is prohibitive and providers complain that they are not being reimbursed for it. They also fear that the legislature will not pass the funding necessary to increase the nurse aide hours, but that facilities will still be expected to meet the required staffing minimums. Consumer advocates noted that they would prefer that staffing minimums be designated by shift rather than for a 24 hour period. They are also concerned that the industry circumvents the staffing requirements by shifting tasks and duties to nursing assistants. Provider association staff also expressed concern that some facilities were eliminating housekeeping positions and shifting housekeeping duties to nursing assistants. Impact of Florida's Quality Improvement Programs on Quality of Life/Quality of CareNo formal evaluation of Florida's quality improvement programs has been performed to date. AHCA staff reported that they are interested in evaluating the success of the programs, particularly the TA component. However, because the programs have been operating only a short time, it is not yet possible to evaluate their impact. Because many of the programs were implemented simultaneously, it will be difficult to measure improvement or to attribute improvement solely to any one program. Uncertainty about appropriate measures also makes the evaluation complicated. A decrease in the number of deficiencies cited, a decrease in overall scope and severity, or a decrease in the number of citations have been considered as possible measures by AHCA, but none is yet considered to be reliable. AHCA has been tracking liability claims and reported that they have been tapering off since they peaked in October 2001 (which was the deadline for all claims). They produce an annual report on adverse events and survey citations, which was due to be published in December 2002. They stated that they have not seen big changes in the aggregate of deficiencies, but that it is too early to see changes especially those that would be related to the passage of SB1202. Agency staff are also aware of the impact staff turnover both at facilities and within the TA program has had on program effectiveness and sustainability, making them hesitant to begin an evaluation that does not take turnover into account. Facility staff turnover was described as being particularly concerning, with some QMs reporting that they were seeing a new Director of Nursing at each facility visit, and finding that QM reports and recommendations were often lost in the transition. Dr. Acker stated that anecdotal evidence indicates the TA program is having positive effects, however. As described in the previous section, many providers we spoke to noted that they felt that the quality of care in their facilities had improved as a direct result of the visits. AHCA also has received positive feedback from surveys and feedback forms used to gauge the success of the Quality Monitoring program. They have conducted two surveys--one with field office managers on the relationship between monitors and field office staff, and one with providers on the value of the monitor program. AHCA also receives feedback from facility staff in the form of a paper questionnaire given to facility staff at the end of a visit, asking facilities to provide information rating the performance of the TA staff and how helpful the visit had been. Most comments have been complimentary, with observations such as the visits were helpful and that staff at facilities were pleased to have someone to ask when questions arose. However, at the time of our visit, AHCA was revising the form and hadn't used it for six months. Some providers we spoke with also said that they are reluctant to offer criticism on the questionnaire for fear that there could be negative repercussions from a Quality Monitoring staff that increasingly has ties with the survey process. Regarding the Gold Seal Program, many comments we heard from providers and consumer advocates indicated they thought the program probably was unlikely to affect quality. Some stakeholders voiced the opinion that the award was primarily a marketing tool which may become increasingly relevant when bed occupancy is lower. They felt that the greatest impact may be on those facilities on the cusp of providing higher quality care which are deciding whether to make the investments that quality improvement requires. For those facilities, the Gold Seal program could make a positive difference. Assessing the value of the Alzheimer training program, most stakeholders said they thought it provides good information, and that it is was most likely to have a positive impact for nursing aides and for facilities that do not have a specific dementia care unit. But some expressed the opinion that facilities would benefit more from being able to choose for themselves the training that would most benefit their facility. And some said mandatory training felt more like a "big brother is watching" regulatory approach than a valuable educational program that improved quality of care. Florida's web-based public reporting program was considered sufficiently valuable by consumer representatives that they said they thought that every state should have one. But a number of stakeholders stated their belief that a several factors were currently limiting its impact on quality improvement. They thought that consumers frequently do not know that the Guides and Watch List exist, may not have internet access, or may not be proficient in navigating the internet. Some provider representatives also noted that some facilities have been on the Watch List many times, and that this does not appear to have provided sufficient motivation for those facilities to do a better job. Stakeholders said that they believe public reporting of deficiencies can improve quality of care provided by stimulating competition and sparking change in facility culture. However, one provider representative stated that since 90 percent of admissions come from the hospital, the discharge planner has the greatest influence on where patients go, rather than a family member who had taken the opportunity to review quality ratings. He posited that as consumers become more computer savvy, interest and impact will increase--and that would make facilities be more concerned about how they look on the public reporting website. Opinions varied about whether the mandated increases in staffing had impacted quality. Some providers said they spent a huge amount of time and money on this issue and it had not made any impact on quality. Another said the belief that by increasing staffing, turnover will be decreased, and that increased staffing creates more flexibility, increases the ratio of staff to residents and improves the quality of life for the residents by allowing staff able to spend more time with them. As with all of Florida's quality initiatives, the impact of the risk management program has not yet been formally evaluated. AHCA staff and provider representatives reported that the number of lawsuits has declined, but it is impossible to know whether this is due to improved quality processes, or whether the number of facilities "going bare" (operating without liability insurance) has made the state's facilities less attractive targets for litigation. Regardless, several providers expressed the belief that the risk management program had been one of the quality initiatives that had the greatest impact on nursing home quality of care. They reported that at first there was resistance to changes such as monthly meetings of the risk management committee, but they now see it as very useful. "It forces us to keep focused." One provider reported that they now do a lot of education around risk management with staff. When staff understand the goals, they stated that their participation and openness increases and they are less defensive. Another provider said that the way that they investigate bruises has changed dramatically since the risk management program was instituted and that how they do their investigation has impacted quality on each nursing unit in their facility. Sustainability and Lessons LearnedCurrently, funding for Florida's quality improvement programs comes from general revenue and licensure fees with some federal funding. AHCA staff noted that there is general support for quality initiatives among members of the legislature. Other state agency officials offered that there has been a focus on seniors, primarily because of the large elderly population, and that the governor and the legislature are committed to seniors' issues. State agency staff also noted that the programs are up for review every year and that the funding for the both the Medicaid Up and Out program and for the Consumer Satisfaction survey have been cut, and that continued support may be tied to demonstration of positive outcomes in the future. We asked providers, state program administrators, and consumer representatives we spoke with in Florida for lessons they have learned and any recommendations they wished to offer other states considering quality improvement programs. Nearly all we spoke to would recommend the Quality Monitor program, which was generally characterized as having a positive impact on facility quality of care. Quality Monitors have been able to establish a more collaborative, less adversarial relationship with nursing facilities than is typical for surveyors, and this relationship allows providers the opportunity to have an open dialogue with TA staff about problems and issues in resident's care, to obtain information on good clinical care practices, and to receive feedback on how they can improve their care processes. Some stakeholders felt the intervention should be targeted either to the smaller free-standing facilities with no corporate support, or to facilities that were having more problems. Most providers said they wanted to see the program continue, remain confidential and separate from survey. They especially wanted the content of the visits not to be shared with surveyors or to be available for litigation. Most said they would prefer that the QM staff not overlap with survey staff--they should be kept entirely separate. However, some providers said that surveyors and Quality Monitors should be trained to provide consistent guidance, and felt that TA staff with past survey experience were most valuable in helping them interpret applicable regulations. All agreed that Quality Monitors needed to be well qualified and experienced in long-term care. Discussants also had recommendations on several of the other quality improvement programs Florida has initiated. Consumer advocates supported the public reporting website as important for consumer decision-making. They believed that the algorithm for ranking facilities is good, but they don't like the fact that every facility gets a star regardless of how low its quality rating is, and would prefer a numeric ranking. Provider representatives recommended that the website resolve problems associated with the reporting of 45 months of survey and deficiency information by showing current performance alongside historical performance. They also thought that regular updating was critical for accurate representation of facilities. Regarding the Gold Seal program, participants thought it important to ensure that there is a well-defined consumer advocate position on the selection panel and that the panel performs an on-site inspection of any facility being considered for an award. They also stated that the awards should be reserved for facilities that were truly doing something special for residents and not merely meeting minimum criteria. Provider representatives noted that there is a need for rewards beyond public recognition that make the Gold Seal worth pursuing and that in order to have an impact, it had to be more attainable for more facilities. Finally, numerous stakeholders reported that the risk management program has real potential for prevention, managing losses and minimizing litigation and that it was helping facilities focus on how best to prevent adverse incidents. Role of the Federal Government in Quality ImprovementMuch of the feedback aimed at the Federal Government concerned the issue of reimbursement. One provider representative summed it up by saying that "You cannot separate money from care," and that Medicare and Medicaid programs have to pay reasonably for reasonable care. There has to be more emphasis on alternative care (home care, assisted living) to really decrease the financial pressure on nursing homes. Some providers expressed concerns about some of CMS' policies on quality measures. For example, Florida has low restraint use, but high fall rates. Providers believe that CMS is not looking at how one area of care impacts another and about interdependencies like the relationship between restraint use and falls. They also described problems with CMS classifying resident-to-resident altercations and that special considerations needed to be made for special populations like dementia and head injury patients where they have no alternatives for placement. State agency staff attempting to look at disease management outcomes and measure resource use said they wish that is was easier to access MDS data and resource use for dually eligible patients. Providers also expressed a need for the Federal Government to take a stronger role in the development of best practice recommendations. "We wish we still had AHCPR to do best practices. They were impartial and the information came from researchers and evaluators--not surveyors." Similar direction was sought on end of life care issues, unavoidable decline and the management of expectations of patients and families about realistic outcomes of nursing home care. Summary and ConclusionsSince 1999, Florida has established and implemented a number of quality improvement programs including a technical assistance program, public reporting measures, recognition programs, training/education efforts, risk management requirements and mandated increases in minimum direct care staffing. All of these measures stem from legislative mandates implemented in direct response to concerns regarding the quality of care in Florida nursing homes and the liability insurance crisis. The centerpiece of the quality improvement efforts is the Quality Monitor program first established in 1999. The monitors visit all facilities quarterly, providing education and monitoring for facility staff. They also seek to identify any conditions that are potentially detrimental to the health, safety, and welfare of nursing home residents. The role of the quality monitor has recently expanded to include providing support to field office staff during a closure or immediate jeopardy situation, reviewing the risk management program and records of adverse incidents, and ensuring that staffing requirements are being met. The majority of participants stated that they found the QM visits to be very helpful, describing them as providing objective, non-threatening advice. They particularly appreciated the Quality Monitors sharing information on best practices, recommending educational materials and offering interpretation and clarification of state and Federal rules and regulations. However, many were concerned about the increased blurring of monitor and surveyor roles and the negative impact this could potentially have on the willingness of facilities to openly discuss problems they were experiencing. The risk management program implemented in 2001 is designed to identify incidents occurring in health care facilities, which have an outcome of patient injury and may reflect error in the course of the delivery of health care services. Providers reported that the risk management requirement had improved the quality of care by requiring them to investigate incidents and accidents in greater detail, examine their facility processes for flawed practices, and make changes with the goal to prevent future problems. Although the number of liability claims filed in the state has reportedly been tapering off since it peaked in October 2001, there has not yet been an easing in the liability insurance crisis. Consumer advocates and provider representatives we spoke with had mixed reviews of the quality improvement programs. While nearly all stakeholders would recommend the Quality Monitor and risk management programs, not all believed strongly in the ability of any of the implemented programs to improve quality of care or resident outcomes. In fact, many stakeholders were skeptical that these efforts were sufficient to solve the quality of care problem in nursing homes. They named issues such as the pervasive problem of high staff turnover and inadequate reimbursement as barriers to high quality performance. We are unable to draw conclusions as to what effect any of Florida's quality improvement programs will have on nursing home quality. First, the programs have been in operation for only a short period of time. Second, the state is not performing the type of evaluation necessary for a rigorous impact analysis. Furthermore, there are a multitude of initiatives underway, all enacted during the same timeframe and during a time of changes within the nursing home industry (e.g., declines in occupancy, Medicare skilled nursing facility prospective payment, public reporting of MDS-based quality indicators). Even so, by reviewing the experiences of Florida, we believe some important lessons can be learned that might be applicable to other states considering quality improvement programs. In addition to those described in the Lessons Learned section above, we would add that states planning to implement quality improvement programs should consider the potential need to evaluate these programs--which is being demanded increasingly by program funders in the current fiscal environment--and do their best to design the programs in a manner that will allow their evaluation needs to be met. IowaBackgroundFollowing the completion of the literature review, discussions with stakeholders and the meeting of the Technical Advisory Group, Maryland was identified as one of seven states meeting the project criteria for states with state-initiated quality improvement programs. These criteria include (1) having state-initiated programs in place, (2) having programs that were not reimbursement or payment related, and which (3) included aspects of technical assistance and/or quality improvement. In response to concerns from within the state and the nation at large, Maryland had enacted a number of measures aimed at improving the quality of care in nursing homes. Some (e.g., the quality improvement plan, the "Second Survey") were regulatory measures, while others ranged from educational services to research endeavors that were voluntary programs. Maryland was identified as the initial site visit because their technical assistance and quality improvement programs had been underway for approximately one year and the state is in close geographic proximity to Massachusetts and Washington, D.C. where members of the research team are located. Overview of the Iowa Site VisitThis report describes our exploration of the various quality improvement programs initiated by the State of Iowa. It begins with background information on the programs and how the visit and discussions were structured and continues with a brief history and rationale for how the various quality improvement programs were selected and implemented. A description of the programs follows along with the research team's findings (from discussions with state employees and nursing facility providers) regarding the overall strengths and weaknesses of the programs as well as a discussion on the impact that these programs have had on the quality of life and quality of care of Iowa nursing home residents. It concludes with lessons learned by the state, the sustainability of the various programs and the participants' opinions on the role of the Federal Government in quality improvement in nursing facilities. A Brief Description of Iowa's Nursing Home IndustryIn order to put Iowa in context with the other study states, we have included some descriptive characteristics of the State's nursing home environment. Comparative data presented are from the American Health Care Association (AHCA) web site (AHCA, 2002). There are 470 facilities in Iowa, with 29,535 residents reported as of Spring 2001. The average number of beds per facility is 96, which is slightly lower than the national average of 108. Iowa's median occupancy rate per facility is 84 percent as compared to the national rate of 95 percent. The percentage of for-profit homes is lower than the national average, (52 percent vs. 65 percent) while the percentage of not-for-profit homes is higher (43 percent vs. 28 percent nationally) with few government-operated facilities (4.7 percent vs. 6.5 percent). Fewer of Iowa's facilities are hospital-based (11 percent vs. 12 percent nationally) and dually certified for Medicare and Medicaid (60 percent vs. 80 percent nationally). Impetus for Iowa's Quality Improvement ProgramsNo single event or series of events or situations within Iowa or outside the state were reported by participants as being the impetus for the Iowa quality improvement programs. The development of the programs appears to stem from the vision of several key contributors. First, Iowa Governor Tom Vilsack has long been a vocal supporter of nursing home issues, both as governor and while serving in the Iowa Senate. The appointment of Marvin Tooman, a former nursing facility provider, to the position of administrator of the Health Facilities Division greatly aided in promoting the issue of quality. The current programs are the result of a uniform vision within the restraints of the current state budget crisis. The first quality improvement program, the nursing home report card, was initially the idea of bureau chief, Larry Lindblom back in 1996 or 1997. It started as a web page to provide information to the public, news, and links to CMS (formerly HCFA). He later thought that it could be improved by adding survey results. At the time the Report Card section of the web site was developed, only one other state (Arizona) had done any work in this area and the Federal Government's site was still under development. In 1999, during his first year in office, Governor Vilsack included among his legislative proposals the creation of the Governor's Award for Quality Care in Health Care Facilities. The selection of Marvin Tooman in February 2000, as HFD administrator made him, reportedly, the first person outside the Department of Inspections and Appeals to hold that position. His background and education make him uniquely qualified for the position. Prior to his appointment, Tooman had been CEO and president of his own company, "On With Life," a non-profit post acute care program specializing in brain injury/neurological and pulmonary rehabilitation. Prior to starting "On With Life," Tooman spent 11 years as a resource manager for the Iowa Department of Education's Division of Vocational Rehabilitation. He holds a Bachelor's degree in Education, a Master's Degree in Counseling, and a Doctorate in Administration and he is an Adjunct Assistant Professor in the University of Iowa's College of Education. He received his quality improvement training in the military, having been trained on the Baldrige self-assessment process. He is also a Commission on Accreditation for Rehabilitation Facilities (CARF) surveyor. Toomam explained that CARF standards are very similar to the Baldrige criteria. At the time of our interviews, he was the president-elect of the Association of Health Facility Survey Agencies. In the first nine months following his selection, the department introduced the Quality-Based inspections program in May 2000, the Joint Surveyor/Provider Training in June 2000; the Deficiency-Free certificates in October 2000 and Best Practices program in November 2000. Later in June 2001, the survey questionnaire was introduced. Overall Intent/Vision for Iowa's Quality Improvement ProgramsThe goal of quality improvement programs is viewed as promoting the "culture of quality." Tooman has expressed the department's vision for nursing home quality by writing regularly in DIA's quarterly newsletter, Insight. In the June 2001 issue, Tooman wrote about the department changing the HFD mission statement. He wrote: "Assuredly, within this experience, we are accountable to the state and federal rules that provide a "baseline" for the quality of care that our residents and clients receive. However, we should not be satisfied with merely maintaining the minimum standard of state and federal rules. To that extent the HFD has changed it's mission statement.--"The mission of the HFD is to promote the quality and optimal outcomes of services through a survey process that centers on enhancing the lives of the people served." Tooman puts the responsibility for success on the facilities that are able to introduce and maintain a "culture" of quality care. He went on to state that, "we need to insure compliance with state and federal rules. But rule compliance is a by-product of a quality improvement effort. …First, it is safe to say that the facility is not immune from the problems that nursing homes face on a daily basis. And there may be occasions where they may be deficient with a rule or two. …[T]hey have established a way of operation that speaks to quality services. Some may say that they have a "Quality Culture." Bureau chiefs echoed Tooman's belief in a quality culture, noting that they recognize quality through mechanisms presented in the Baldrige criteria and that they had moved in that direction via a culture change. They explained that they saw themselves as a team "all pointing in the same direction" and that changes had been "strategized and well implemented." Description of Quality Improvement Programs in IowaThis section includes a brief description of each of Iowa's quality improvement programs followed by a discussion of program funding, governance and the management and staffing structure. The following quality improvement programs were reviewed:
Nursing Home Report Card The Nursing Home Report Card is an Internet web site that contains information on all federally certified nursing facilities and skilled nursing facilities in the state. The Report Card allows users to search for facilities by name or location. It includes "quality indicators" (Note: These are F-tags and not the CMS quality indicators) based on survey results. The web site includes the full inspection report, including detailed write-ups of deficiencies and the facility responses/Plans of Correction. All survey/complaint investigations since June 1999 are listed, including those under appeal, with the appeal noted (see Appendix C for a sample facility Report Card). The Report Card also includes information on facility best practices. The legislation that created the Report Cards was passed in late 1997. At that point in time, the CMS Nursing Home Compare site was still under development, and there was little consumer information on nursing homes available on the Internet. The Iowa Nursing Home Report Card went on-line on November 5, 1999. A goal of the Report Card is to provide consumers with information on nursing home quality so that they can make informed nursing home choices. It is believed that provision of this information will motivate facilities to improve quality. The department strongly believes in making information available to consumers, believing, according to Dr. Tooman, that the availability of public information is "sacrosanct" (except when it is necessary to protect confidentiality). Iowa is the only state that researchers are aware of that posts complete survey results on the Internet. The survey findings are posted to the Report Card web site two days after the survey is mailed to the facility. According to an article in Insight, the Report Card website was designed over an 18-month period as DIA worked in collaboration with resident advocates and nursing home industry leaders. DIA met with stakeholders twice as they developed the report card. The group included representatives from the four provider groups, the Iowa Partners group, advocacy groups, ombudsmen, state legislators, and representatives from the Departments of Elder Affairs and Public Health. In the facilitated meetings, DIA presented a shell and asked for input from stakeholders. Quality-Based Inspections Under the Quality-Based Inspection Program, facilities that are state-only licensed may be surveyed every six to 30 months, depending on facility performance. The program was intended to allow DIA to maximize its resources and concentrate more fully on the facilities in the state needing the greatest attention. Legislation authorizing the program was signed on May 11, 2000 (Senate Bill 2144). The quality based inspection program is reported to have originated from provider groups requesting the state to make changes in the survey process. Facilities opting to participate must complete a detailed application process based on the Malcolm Baldrige National Quality Program. The Baldrige Award is given by the President of the United States to businesses and education and health care organizations that apply and are judged to be outstanding in seven areas: leadership, strategic planning, customer and market focus, information and analysis, human resource focus, process management, and business results. Nationwide, there were five winners in 2001. DIA modified the Baldrige application process by shortening the application and broadening the categories to accommodate the limited resources of most nursing facilities. The program, however, has not been truly successful. Very few facilities have opted to participate. There are ten nursing facilities statewide that do not participate in the Medicare or Medicaid programs, and are thus eligible for the program. Three facilities were invited to participate in a pilot program, but only one nursing facility has completed the self-assessment necessary to participate in the quality-based inspections program. Furthermore, the potential benefits from participating (in terms of a less frequent survey cycle) are probably outweighed by the time and effort required to apply. A major component of the Baldrige National Quality Program is the feedback report, which is a written assessment of an organization's strengths and opportunities for improvement based on its application. Due largely to limited staff availability and budgetary restrictions, the Iowa-modified program does not provide any type of feedback report to its applicants. This feedback report had been envisioned as one way, among others, that the department could provide a type of technical assistance to facilities. Best Practices Begun in November 2000, the Best Practices Program aims to recognize and disseminate new and innovative approaches to providing nursing home care. Shortly after assuming the Division Administrator duties, Dr. Tooman observed a surveyor congratulating a director of nursing on a uniquely successful nursing procedure. He believed that the details on this practice should be shared with other facilities and that at the time there were no means to accomplish that. The goal for the program as described by DIA is to close the gap between knowledge and practice and point to positive approaches to integrating new knowledge and practices. Facilities that believe they have developed an innovative practice report it to the surveyor during the annual inspection. The surveyors review the practice on site with the team leader, making the decision as to whether it qualifies as a Best Practice. Those practices deemed to be among the best in the state are recognized and posted on the division's Report Cards and in a separate listing on the web site. Best Practices are sought and recognized in nine categories--community integration, dietary, resident rights, nursing practices, human resource management, environmental, quality of life, habilitation/rehabilitation and end-of-life experiences. Currently, there are 300 Best Practices listed on the web site (note that fewer than 300 facilities are represented since some facilities are recognized for more than one best practice.) Originally, the department's web site denoted best practices with a trophy icon, but this was later changed to a light bulb, as the department wanted to emphasize that the Best Practice program was designed to recognize a facility's practice, not the facility itself. Also, the practice of sending facilities Certificates of Recognition was later changed to the sending of a letter, because of confusion related to certain facilities receiving recognition and then later having problems with survey inspections and/or complaints.Appendix D includes the state's principles and procedures of Best Practices. Joint Surveyor Provider Training Beginning in June 2000, the DIA and the provider associations have collaborated to present four joint surveyor/provider training sessions, with another session scheduled in October 2002. Training sessions have been held on elopement, activity-focused care, dental needs of long term care residents and resident-centered living. The October 2002 session will address pain-related issues. The department initiated the joint training sessions in an effort to provide a common knowledge base for surveyors and providers and to enhance the quality of care and quality of life of the state's residents. The department utilizes local community colleges to assist with the organization of the training with experts in the topic recruited to conduct the actual training sessions. For example, two professors from the University of Iowa College of Dentistry led the training sessions on oral health and Eric Haider, from the Crestview Nursing Home in Bethany, Missouri spoke about his philosophy on resident-centered care. Nearly all of the state's 60 surveyors and 200- 350 providers have participated. Governor's Quality Awards The Governor's Award for Quality Care in Health Care Facilities recognizes quality services provided by long term care facilities, residential care facilities and intermediate care facilities for the mentally retarded or mentally ill. The award is based on the uniqueness of the services provided by the facilities to its residents, and any activities undertaken by the facility to enhance the quality of care or quality of life for its residents. The program was signed into law on May 11, 2000 with the first awards given in 2001 to eight health care facilities. Nominations may be made by residents, family members, advocates and staff at other nursing homes. A stakeholder committee selected by the Director of the Department of Inspections and Appeals reviews nominations. Committee members evaluate each nomination and recommend facilities for further consideration. Prior to the selection of finalists, onsite reviews are made by DIA personnel to verify the accuracy of the information in the nomination. There can be up to two winners in each of the state's five Congressional districts. In 2001, there were 29 nominations and five winners. In the first year of the program, the awards were mailed to seven of the award-winning facilities, with the Governor making a personal presentation at one location. This past year, Governor Vilsack presented the awards at the Governor's Annual Conference on Aging. Deficiency-Free Certificates of Recognition Beginning in September 2000, DIA provides certificates of recognition to facilities that are deficiency-free in their annual inspection. The certificate is the department's way of acknowledging the "hard work and dedication" of the facility's staff in meeting the established standards of care. During the fiscal year that ended in September 2000, nearly 15 percent of the state's 800 long-term care, intermediate and residential care facilities had achieved deficiency free surveys. In March 2001, it was reported that 55 nursing facilities had received certificates. Survey Questionnaire Since June 2001, facilities have had the opportunity to complete a survey questionnaire that is presented at the conclusion of the regular survey. Completed surveys are returned to the Iowa Foundation for Medical Care (IFMC) for tabulation. IFMC estimates that 40-50 surveys are returned each month. The goal of the questionnaire is to improve the survey process in the state, ultimately improving the provision of health care services in the state. The survey includes information on surveyor conduct; facility opportunity to provide information and survey-related data; clarity of exit conference information; and whether the facility received information on the Best Practices program. Providers are also given the opportunity to provide general comments on the survey process, including suggestions on how to improve it. IFMC produces a report for DIA in an Excel spreadsheet, which DIA in turn shares with their staff. In May 2002, the state average was 4.62 (on a one to five scale with five representing the most favorable rating). Data are stratified for each program coordinator so that specific areas for improvement can be identified and addressed. Aspects of Iowa's Quality Improvement Programs that Work WellProvider representatives overwhelmingly agreed that recognition programs (Deficiency Free Certificates, Governor's Quality Award, and Best Practices) did much to boost nursing facilities' morale. Over and over, participants stated that in the heavily regulated and scrutinized nursing home environment, facilities were grateful for positive recognition. Stakeholders told us that receipt of such awards was sometimes publicized in community newspapers and local media. Both provider associations agreed that the Best Practices program was a good informational resource for facilities as well as providing recognition for exemplary programs. The Nursing Home Report Card was generally recognized as reporting current, accurate information, although there is considerable controversy regarding the posting of survey results that are under appeal (see further discussion below). Bureau chiefs reported that it had cut down on telephone requests for survey information and had saved considerable staff time sending out paper copies of survey results. Bureau chiefs and the Ombudsman agreed that the report card had done a good job improving consumer access to public information. According to division web site statistics, the web site is widely used with 14,664 sessions recorded in June 2002 (this does not represent unique users since some individuals may have accessed the web site multiple times). The Report Card pages are among the most accessed on the division's web site, with 7,050 hits to the report card result summaries, 5,945 hits on the detailed facility results, almost 5,000 hits to the report card search page and 2,292 viewings of the detailed survey findings. Although it is not possible to determine the identity of web site users, they do represent nearly every state, as well as Europe and Asia. According to one of the Bureau Chiefs, report card utilization had gone up 50 percent in the last six months. In September 2000, GovNetworks and eGovernment magazine recognized the division web site with their Digital Award of Excellence, which is intended for deserving web sites that benefit the public. Joint Surveyor/Provider trainings have been well attended--600 attended the first programs (elopement prevention), 200 attended the programs on creative care giving, 300 attended the oral health training, and 300 participated in the programs on resident centered care. Joint trainings may have helped improve relations between facilities and surveyors. Based on feedback forms, providers find these sessions very informative and useful. The Survey Questionnaire reportedly has increased surveyor accountability, and has encouraged them to be more courteous, communicative, professional and approachable. Provider associations were pleased to have had input in the development of the questionnaire. Aspects of Iowa's Quality Improvement Programs Noted to be Less SuccessfulAlthough there was agreement that nursing facilities appreciated recognition for good performance, there was concern expressed by the Ombudsman that these awards gave consumers a false sense of security. In their experience, they noted that consumers seeing a Best Practice icon on the website or a Deficiency Free Certificate assumed that the facility was performing well in all care areas on a consistent basis. In fact, as they pointed out, a Deficiency Free Certificate only attested to the facilities' ability to meet minimal standards for the days that the surveyors were in the building. Likewise, recognition of one good area of practice did not mean that all practice areas were exemplary. HFD surveyor trainers noted that advocacy groups had been critical that these award programs were seen as bringing the regulatory agency too close to the entity they were supposed to be regulating. The Ombudsman also noted that the requirement that the Best Practice be reported and evaluated during the survey was burdensome for facilities. They recommended that the recognition of Best Practices not be tied to a particular facility, but listed separately on the website. One of the most difficult situations for all parties to contend with concerned those facilities that had received recognition for a practice or deficiency free survey and then later had compliance problems. These situations had been widely reported in the news media by an individual reporter who focused on long-term care issues. Initial praise and recognition of a facility that subsequently falls into disfavor was reported by participants as making the whole process look suspect. Another very controversial issue concerned the posting of all deficiencies on the web site, including those that were under appeal. The HFD policy is to post them two days after they are mailed to facilities and if appealed by the facility to mark them as such on the website. Both provider associations had unsuccessfully attempted to block the posting of deficiencies under appeal. Provider associations stated that even when deficiencies were later overturned, the damage from the initial posting and subsequent publication in the media was not readily reversed. Appealed postings are noted as pending appeal. The third most widely expressed concern with the Nursing Home Report Card posting of deficiencies is that it is claimed by some industry representatives to have had an impact on nursing home liability insurance rates. According to the AHCA representative, based on the number of deficiencies, some insurance companies were not writing policies and others had increased rates to the point that they were unaffordable by facilities. According to the department's Deputy Director, the governor convened a task force to examine insurance issues generally. The Task Force report does not note any connection between rates/availability of insurance and the web site report card postings. Other more minor issues with the Nursing Home Report Card concerned the ease of consumer use. The Ombudsman pointed out that consumers were confused by the listing of complaints that were found unsubstantiated. Complaints that are not substantiated are not written out in their entirety. They recommended that all complaints be posted so that trends over time could be evaluated. The provider associations also felt that more collateral materials should be included on the website to aide consumer understanding of the information posted. They also disagreed with the inclusion of the names of directors of nursing and administrators in several years worth of data, noting that if these individuals are no longer employed because of poor performance their information remains on the web site. Participants were mixed in their impressions as to how widely the Report Card was used by consumers. Consumer advocates noted that many consumers do not know that it is out there and that especially in many rural situations, there may only be one facility within a reasonable distance of family members and in this situation there could be little benefit to using the report card for facility selection. There was widespread agreement from all participants that the Quality-Based Inspections program had not been successful as the application process was generally too burdensome for the majority of facilities to complete. Only ten nursing facilities are state-only licensed and even though the program had been modified in an attempt to streamline the process, only one had applied to participate in the program. Additionally, the benefits from applying for the quality-based inspections were reported as, "not worth the effort." The potential benefit is that the survey cycle could be extended to as long as 30 months. And, even for facilities that qualify for an extended survey cycle, some type of annual follow-up (a validation review) is required to make sure that the facility is still performing at the high level required to justify the longer survey cycle. The validation review involves one or two surveyors on site for no more than two days and involves a quality assessment based on the program's criteria. The State's Ombudsman reported that the philosophy of the quality-based inspection program "scared them." They believed that there could be large changes in provider quality after the inspection (i.e., in the case of "yo-yo compliance") and are opposed to any program that would increase the length of time between inspections. Provider representatives reported that facilities were not convinced that responses on the survey questionnaire were completely anonymous. Even though the forms are sent to the Iowa Foundation for Medical Care for tabulation, providers are fearful that surveyors have access to the survey feedback information. Provider associations reported that comments they received from facilities regarding surveys were not consistent with the survey results that they had received from HFD. Either facilities were not completing the survey or were being overly generous to HFD in their rankings. The provider association also believed that individual surveyors should be named on the questionnaire rather than be reported at the coordinator/supervisor level. In their opinion, the naming of individual surveyors would lead to individual employment counseling where indicated. IHCA has developed and begun distributing its own questionnaire, which is similar to that used by DIA (except that it includes surveyor-specific questions) so that the association may compare its results with those obtained from the department questionnaires. Joint provider/surveyor training was praised for providing access for both groups to up-to-date clinical information although progress toward its secondary goal of opening up communication between the two groups was seen as marginal. Participants noted reluctance on the part of both groups to asking questions in the group setting, as providers did not want to share areas of facility weakness and surveyors did not want to look uninformed in front of providers. Surveyor trainers also noted that by providing these joint training sessions, they necessarily had to cut back on the number of surveyor-only meetings for budgetary reasons. Also, provider associations initially objected to the issuing of continuing education units for these programs, as the income from offering educational programs has traditionally made up a major part of their revenue. Impact of Iowa's Quality Improvement Programs on Quality of Care/Quality of LifeNo evaluation of the impact of these programs has been made to date. Some decrease in the number of deficiencies has been noted in recent years, but it is not clear that there is any connection between the quality improvement programs and the number of deficiencies cited. Although there are statistics available on how many people access the website, there is no information as to whether these users are consumers, policymakers, researchers, or others. It is not known how the Report Cards affect consumer choices or facility quality. With only one nursing home in the state having applied to participate in the Quality-Based Inspections program, it is clear that this program, as implemented, has not had any impact on the quality of care or the quality of life for Iowa nursing home residents. Based on informal polling of providers, Dr. Tooman reported that the majority of providers have at least looked at the best practices, and he has anecdotal evidence that some facilities have adopted the best practices of other facilities. Ombudsman did not note any significant improvement in care since the implementation of the quality improvement programs. They explained that, for example, the Governor's Award program, "It's nice and warm and fuzzy, but we don't really know that it improves care." They went on to say that these programs have focused on the average and above average facilities and have not raised the standards or done enough to deal with the poor performers. They believe that many of the best practices just represent activities that the facility should be performing routinely and do not represent exceptional care. They also believe that many facilities do not nominate themselves for a Best Practice Award believing that these practices are simply, "part of their job." One provider representative stated that, "nothing improves quality more than reimbursement." She went on to say that although award programs are going in the right direction--the number one and two issues for facilities are reimbursement and consultative assistance and that these are the issues that facilities would like addressed--the "rest of this is just window dressing." Sustainability and Lessons LearnedExcept for the Quality-Based Inspections program, discussion participants did not identify any programs noted as unsuccessful or at risk of discontinuation. The department places great importance on making information available to consumers. There were no plans to add additional items (e.g., staffing information or MDS quality indicators) to the Nursing Home Report Cards. When CMS begins posting the quality indicators, the department will include a link to this site. AHCA representatives advised other states to carefully consider all aspects of a report card and to have as much detail on the description, development and implementation as possible written into the legislation. They advised other states to consider what information will be seen by the public, how it will be displayed, timeframes for display, and how much collaboration there will be in the development process as examples of the types of topics that should be clearly defined prior to enactment. They noted that when the legislation to develop the Iowa report card was passed, it sounded acceptable, but later they found that DIA's interpretation of the legislation varied significantly from their interpretation, which led to the current problems regarding the posting of deficiencies prior to the resolution of appeals. Ombudsmen stated that they would like to see all complaints posted, including those that are not substantiated. They also advised that more advertising is needed to let consumers know that the report card is available. There was general agreement that the application for the Quality-Based Inspections program needs to be simplified and the benefits for eligible facilities enhanced. Until CMS is willing to consider an alternative survey process which differentiates between good and poor performers, programs designed to make it possible for good facilities to be surveyed less often will not work if they can only be applied to state-licensed only nursing homes, given that most homes participate in Medicaid and/or Medicare. Participants believed that programs rewarding best practices and deficiency-free surveys were valuable, despite the potential fall-out if those facilities later run into problems. They pointed out that it was important to have an objective process by which facilities are judged, so that the award is seen as truly recognizing outstanding quality and not based on other factors such as politics. Both provider groups and the department indicated that they were pleased with the joint training programs and would recommend these to other states. High attendance at the sessions is indicative of the value that providers place on the training. DIA trainers suggest that states collaborate with community colleges and universities in the development of curriculum and presentation of materials. They also suggested that since provider associations usually have had more experience in planning and presenting educational programs, the states use them as resources. States should also consult with provider associations so as not to duplicate topics. DIA trainers also noted that states should avoid controversial topics, such as regulatory issues, and select "safer" topics, such as clinical issues. The survey questionnaire was reported to be a relatively inexpensive way of improving the survey process, increasing surveyor accountability, and allowing facilities to provide feedback to the department. DIA recommends it to other states interested in these outcomes. Role of Federal Government in Quality ImprovementDr. Tooman explained that he prefers that the Federal Government take the lead on providing "technical advisement" to states and facilities on quality-based cultures and organizational processes. Although the Quality-Based Inspections program, based on the Baldrige criteria was less than successful in Iowa because of its complexity and the limited resources available to most nursing homes, he remains a strong proponent of the process, having been a trainer prior to joining HFD. He believes that through technical assistance, facilities can be "equipped to do a better job. Summary and ConclusionsBudgetary issues emerged as having a significant impact on the department's current programs and plans for future quality improvement programs. Iowa had experienced a 4.6 percent cut in last year's budget, plus additional cuts that amount to about 4.6 percent for this year. Despite the Governor's support for long-term care issues (he introduced a bill that would have allowed the state to shift resources so that budget cuts would not need to be as large) the general assembly rejected this proposal. Due to the budget cuts and expanded responsibilities (DIA recently assumed the responsibility for regulating assisted living programs), the concern for DIA has been to maintain current QI programs, as it is currently not feasible to implement new programs. Provider group representatives expressed their desire for a consultative component to the survey process. They appreciate the recognition programs and awards, but identify the lack of "someone they could call for help," as a problem. Other than higher reimbursement, some type of technical assistance is what facilities want most from the state. Dr. Tooman noted that he has interest in implementing a technical assistance program, but the lack of available state funding in combination with additional DIA responsibilities make such an undertaking not feasible at this time. Funding remains a difficult issue. Another significant influence on quality improvement programs in Iowa comes from the media. The State's major newspaper, the Des Moines Register, has focused a great deal of attention on long-term care issues, raising public awareness of quality in nursing homes and assisted living programs. The Nursing Home Report Cards are a major source of information for these articles and attention has been given to homes that receive awards, but are later cited for major deficiencies. During the site visit, the Register began a major series on assisted living programs. The attention generated from previous articles on these programs reportedly led to the change in oversight responsibility from the Department of Elder Affairs to DIA. Finally, Dr. Tooman's background as a former facility chief executive officer and administrator and his sensitivity to facility issues appear to have contributed to the direction that DIA has taken in developing and implementing its quality improvement programs. DIA has made an effort to recognize facilities doing exemplary work, to improve relations between providers and surveyors, and to encourage facilities to engage in continuous quality improvement. ReferencesAHCA. State Summaries of Nursing Facilities, 2001/www.ahca.org/research/keynotes/statefactsheets-2001.pdf. Iowa Department of Inspections and Appeals. Governor Unveils Nursing Home Report Card Site. Insight, February 2000. Tooman, M.L., Department, Health Care Providers Share Common Responsibilities. Iowa Department of Inspections and Appeals. Insight, June 2001. Tooman, M.L., Presentation Sparks Motivation for Quality Care. Iowa Department of Inspections and Appeals. Insight, September 2001. MaineOverview of the Maine VisitMaine was selected for a site visit because it met the criteria established by the research team and Technical Advisory Group in that it has established and funded quality improvement programs, which are not reimbursement related. Researchers were particularly interested in Maine because of the unique technical assistance component within the quality improvement programs. Maine's technical assistance program, in existence since 1994, consists of one nurse who provides consultation and educational inservices statewide to any long term care facility on problem resident behaviors. The Technical Advisory Group believed that Maine's small technical assistance program might serve as a model to other states that were interested in providing technical assistance to nursing facilities but not able to implement a large-scale program. The State also recently enacted legislation that mandated a Best Practices Program, a consumer satisfaction survey and measures to significantly increase their minimum nurse staffing ratios. A Brief Description of Maine's Nursing Home IndustryIn order to put Maine in context with other study states, we have included some descriptive characteristics of the state's nursing home environment. Comparative data presented are from the American Health Care Association (AHCA) website (AHCA, 2002). There are 126 facilities in Maine, with 7,309 residents reported as of Spring 2001. The average number of beds per facility is 65, which is lower than the national average of 108. Maine's median occupancy rate per facility is 91 percent as compared to the national rate of 87 percent. The percentage of for-profit homes is higher than the national average, (71 percent vs. 65 percent) while the percentage of not-for-profit homes is lower (25 percent vs. 28 percent nationally) with few government-operated facilities (4 percent vs. 6.5 percent). Fewer of Maine's facilities are hospital-based (9.5 percent vs. 12 percent nationally), but there is a higher percent of facilities that are dually certified for Medicare and Medicaid in Maine (100 percent vs. 80 percent nationally). The state has seen a dramatic shift in the composition of its nursing home population in the past nine years, most likely as a response to the state's case mix reimbursement system and other long-term care reform (e.g., requiring facilities to increase their participation in Medicare by certifying more beds) that were implemented beginning in 1994.5
5. The source of the information presented in this section is the State of Maine Long-Term Care Status Report, December 2002, http://www.state.me.us/dhs/beas/ltc/2002/ltc_2002.htm#nursing. Impetus for Maine's Quality Improvement ProgramsOverall Intent/Vision for Maine's Quality Improvement ProgramsThere are two goals identified for the Behavioral Consultative services. The first is that by assisting facilities to provide better services, the risk of abuse and neglect of these residents with problem behaviors will be reduced. Secondly, the number of discharges of these residents from facilities because the facility cannot deal with the resident will also be reduced. Best Practices, Consumer Satisfaction and Minimum Nurse Staffing Ratios are intended to improve quality outcomes, according the legislative study. Best Practices and minimum staffing were envisioned as means to enhance the lives and safety of the consumers. The committee developing the educational Best Practice programs sought to provide both regulatory and practical guidance for facilities on meeting resident needs. Innovative ideas from nursing facilities were solicited to aid other facilities in maximizing quality outcomes within the confines of limited staffing resources. Contacts in the Ombudsman office believe that a multidimensional approach to measure quality is necessary--no single measure can do an adequate job. They expressed their belief that the consumer satisfaction survey would be one component along with quality measures and enforcement activities to improve quality for Maine long-term care residents. Description of Quality Improvement Programs in MaineThis section includes a brief description of each of Maine's quality improvement programs followed by a discussion of program funding, governance and the management and staffing structure. The following quality improvement programs were reviewed:
Behavior Consultation Laura Cote RN is the sole technical assistant in Maine, providing on-site consultation to any long-term care facility (nursing facilities, assisted living facilities, intermediate care for the mentally ill, facilities caring for head injured, adult family care homes and boarding homes) on problem resident behaviors any where in the state. Growing out of her experience as a member of a transition team closing a facility that cared for primarily psychiatric residents, she became aware of the need for support and education for long term care staff. She currently provides consultations in the morning and inservice programs in the afternoons on a full-time basis, working from her home office. Technically an employee of the Division of Licensing and Certification, she receives referrals from facilities and schedules on-site visits and inservice programs throughout the state. Ms. Cote describes the goals of these services as "to assist staff in dealing more effectively with difficult behaviors by giving them a better understanding of the resident, why the behaviors are occurring, making recommendations, involving them in team problem solving where their input is valued, and providing them the education that will enable them to do their jobs more effectively and safely--as well as improving quality of care and ultimately quality of life for the resident."6 Ms. Cote, depending on the severity of the problem, prioritizes responses to facility requests. Visits are generally made within two weeks of the request. Inservice programs are very popular and are currently being booked well into 2003. On-site consultation visits involve a chart review, problem-solving sessions with staff (including all staff involved in care), a brief meeting with the resident, written recommendations, and a follow up if needed. When speaking with the staff during the problem solving session, they discuss the problem behaviors in detail, including what the warning signs are, what helps, and what doesn't help. Using staff input, she writes her recommendations by hand because she believes that they are more personal. The recommendations are geared to the care providers and reflect the information that they offered in the earlier session. Copies of her recommendations are forwarded to the facility and to the Division of Licensing and Certification. Facility recommendations are available for surveyors' review although facilities are not held accountable for implementing Ms. Cote's recommendations. Appendix B contains a sample of the facility feedback report that is prepared at the end of a behavioral consultation visit. Ms. Cote has also developed seven in-service programs, which she conducts at facilities on request. Program topics include: Behavioral Approach, Documentation of Behaviors, Alzheimer's--Practical Hints for Caregivers, Intimidating Behaviors, Problem Solving for Difficult Behaviors, Behavior Profile Cards, and Elopement--Risk Factors and Prevention. In-service outlines are included in Appendix B. No formal evaluation has been done, but Ms. Cote distributes evaluation sheets intermittently to see if there are ways she can improve her service. Best Practices Best Practice workshops were mandated as part of the April 2000 legislation to address nursing home issues. The Department of Human Services was charged with participating in a "series of best practices forums to provide educational workshops and opportunities to providers of long term care services." Led by the Assistant Director of Licensing and Certification, a task force was assembled to implement the legislation. Beginning first with determining a definition of a best practice the task force proceeded to identify topics and plan two workshop programs. The first program on Nutrition and Hydration was an all day workshop offered in two locations. It began with a presentation on the federal regulations regarding nutrition and hydration led by a federal surveyor followed by a panel presentation by providers who discussed nutritional practices that worked best for them. Prior to the workshop, all providers in the state had been asked to submit examples of nutritional best practices. Panel participants were selected from those who had provided a best practice. The audience included administrators, directors of nursing, staff nurses and nursing assistants. The Licensing and Certification division reported that 90 percent of all homes in the state sent staff to one of the workshops. The second program was on Incontinence and featured an expert speaker. The audience consisted mainly of nurses because of the more clinical nature of the forum. The second workshop was not as well attended as the first due to inclement weather on the scheduled date. No formal evaluation of the impact of either program has been conducted as yet. Minimum Staffing Ratios Also included in the April 2000 legislative mandate was an increase in nurse staffing requirements. Nurse staffing is defined in terms of ratios of direct care staff to residents by shift. Direct care staff include charge nurses, medication nurses and aides and nursing assistants, but not nurse managers, supervisors, directors of nursing or MDS coordinators. Day shift ratios increased from 1:8 to 1:5; evening shift ratios increased from 1:12 to 1:10; and night shift ratios increased from 1:20 to 1:15. Staffing is reviewed during the annual survey (and during any complaint investigations related to staffing) for a two-week period prior to the date of survey. If problems are noted, surveyors will review other periods as well. If a facility is out of compliance on one shift on one day, they may be cited. Consumer Satisfaction Survey Funds to develop a consumer satisfaction survey were included in the April 2000 legislation. Proposals were solicited and a contract was awarded in the Fall of 2002 to Market Decisions, LLC, a Maine survey research firm. This company will conduct a face-to-face survey of a sample of nursing facility residents to determine their satisfaction with their surroundings and the care they receive. The study report is expected in late Spring 2003. 6. Laura Cote. Description of Behavior Management Consultation. September 2002. Aspects of Maine's Quality Improvement Programs Noted to Work WellThe Behavioral Consultation offered in Maine is well received partially because although organizationally housed within the Division of Licensing and Certification, it is completely separate from regulatory activities and because there is no cost involved for facilities. Contributing equally to the program's effectiveness is the experience and qualifications of the individual who is solely responsible for it's structure and content. Laura Cote is seen as knowledgeable, credible, familiar with the long-term care environment and able to communicate well with both licensed and unlicensed staff. Because Ms. Cote works from her home, facility staff were often not aware that technically she works within the Division of Licensing and Certification. Participants were unanimous that Ms. Cote's consultation was helpful not only to residents but to staff as well. One director of nursing stated that by soliciting staff input, particularly from nursing assistants that Ms. Cote was able to diffuse difficult situations that could potentially lead to physical and/or verbal abuse. Ms. Cote has a reputation of being able to glean from a record relevant care information that staff had either missed or considered insignificant. Another nursing director noted that even though the problem behaviors often could not be eliminated, the discussion around them gave all levels of staff, the nursing assistants in particular, insight as to why these behaviors were occurring and support to continue their efforts at dealing with them. The separation from the surveyors makes the facility staff feel comfortable interacting with Ms. Cote. One director of nursing noted that often their record of having consulted with Ms. Cote improved survey outcomes as it demonstrated to the surveyors that the facility was taking appropriate action to improve certain problematic situations. Providers noted that the careplans that Ms. Cote develops and leaves with the facility were organized, detailed and very useful, but emphasized that the process of speaking with (and listening to) staff was an equally important part of her service. The inservice programs that Ms. Cote offers were noted to be well attended, to the degree that facility staff came in on their days off so as not to miss them. Nursing directors explained that Ms. Cote's presentations are "down to earth," and appropriate for all staff. The programs include many examples from Ms. Cote's own experience that staff are able to relate to and learn from. Providers also praised the Best Practices workshops and hoped that additional ones would be planned. The panel discussion that occurred as part of the Nutrition and Hydration workshop was noted to be particularly helpful. One nursing director stated that their facility had initiated some new approaches to dining after attending that workshop and had adopted some of the ideas into their quality improvement program. Aspects of Maine's Quality Improvement Programs Noted to be Less SuccessfulAlthough participants were overwhelmingly pleased with Laura Cote's work providing behavioral consultation for nursing facilities, some noted that having only one person to cover the entire state did not allow adequate follow-up activities with facilities. With additional staff more inservices could be provided, response time could be shortened (although not considered a problem by facility staff contacted) and a greater degree of follow-up consultation could be provided. The minimum staffing requirement, although no one would disagree that it was an important component to improving quality, was difficult for facilities to meet in view of the current nursing shortage in the state. Facilities reported having trouble finding an adequate number of qualified staff before the required staffing was increased and now frequently have to rely on temporary agency staff, a practice they feel does not contribute to quality of care. When initially proposed, the required staffing was discussed in the aggregate and not as ratios of direct care staff per shift. Facilities are reportedly being cited for numbers below the requirement. One facility stated they had been cited for staffing on the day shift of 5.06 residents per direct care worker when the requirement was 5.00 residents per staff person. Facilities also stated they would have preferred a greater degree of flexibility in the regulation so that they could staff according to their residents' needs--staffing even higher than required during certain peak times of the day and less when residents' needs were less intense. Staffing below the required numbers is supposed to lead to a self-imposed moratorium on admissions. Facilities that are Medicaid certified must maintain a 90 percent occupancy rate to avoid having their funding affected. This creates a difficult situation where facilities must chose between regulatory and financial compliance. Impact of Maine's Quality Improvement Programs on Quality of Life/Quality of CareParticipants believed that the quality of life for residents referred to Ms. Cote for behavioral consultation was definitely improved because staff are able to provide better care to this difficult population. Although no formal evaluation has been conducted, anecdotal feedback from survey staff, ombudsman and providers indicated that the consultations have led to changes in plans of care that have had positive results for both residents and staff. The survey staff respondent indicated that based on informal feedback she has received, the education and support given to staff has decreased medication use among the residents and has also decreased the number of discharges due to behavioral issues. In her experience, in homes without support, the staff had on occasion become so frustrated with problem residents they would discharge the resident to an acute care setting and refuse to readmit them, preferring to take the deficiency citation rather than continue dealing with the resident. There has been no formal evaluation of the impact that the Best Practices program or the increase in minimum staffing requirements have had on quality of care or quality of life. Providers reported adopting ideas presented at the Best Practices workshop, particularly the one on Nutrition and Hydration and incorporating these practices in to their quality improvement programs. Sustainability and Lessons LearnedParticipants did not indicate any plans to change the behavioral consultation visits, although some recommended that expanding the program would be advantageous. Current budget constraints limit any plans in this direction. The survey respondent stated that any additional funds would most likely to be used to hire more surveyors. The legislative mandate that created the Best Practices program was not specific to the number of educational programs that were to be provided, except to state that the "Department of Human Services will participate in a series of best practices forums…" The survey respondent who headed up the program planned to reconvene the program's Task Force to begin planning future activities. Some ideas, although not firm were to investigate activities in this area in other states and/or possibly make Best Practices available in some sort of publication. There was some discussion by participants to re-examine the minimum staffing requirement. Although all contacts voiced support for the principle of improved staffing, there were some thoughts of possibly modifying the language of the regulation to allow facility staff more latitude in managing the numbers. Proponents of the increased minimum ratios did not want to have to go back to the legislature to re-write the regulation, but rather were hoping for increased flexibility in the interpretation of the regulation in view of the current nursing labor shortage. Participants advised other states that funding passed to implement increased staffing should be proposed as ongoing and not limited to the year the measure was passed. When questioned regarding recommendations for other states, participants enthusiastically advised that, "Every state should have a Laura Cote." One respondent cautioned, however, that every state is unique and what works in one state may not work in another. This comment addressed the fact that Ms. Cote works alone covering the whole state and that often facilities wait up to two weeks for a requested consultation. Facilities in Maine accepted the two-week wait for consultative visits, possibly because many of them are located in rural areas, and are accustomed to not having services readily available. Participants advised that with any consultative or technical assistance program that the qualifications and experience of the hired consultants was critical. For behavioral consultations to be successful, they noted that a potential consultant needed to be well versed in clinical, psychiatric and long-term care issues. Because of the diversity of diagnoses present in the long term care population, being an expert in only one of the aforementioned areas would not be adequate to provide facilities with valid and useful information. Role of the Federal Government in Quality ImprovementThe Ombudsman stated that regulations alone are not enough to improve quality. She believes that multiple and varied approaches must be utilized to assist facilities in their quality efforts. Adequate numbers of, and respect for, staff is one such area. Another approach involves improving access for facilities to clinical informational resources and the provision of technical assistance. Lastly she pointed out that efforts to decrease staff turnover must occur. According to the Ombudsman, the role of the Federal Government should be to provide education. The survey agency respondent agreed stating that the Federal Government should continue to provide enforcement but also add training and initiatives focused on helping facilities deal with problems. Providers had expressed interest in accessing information on Best Practices, particularly in the areas of pain management and elopement. Summary and ConclusionsMaine's quality improvement programs consist of the long-standing but limited behavioral consultation and the recently enacted educational and staffing requirements. Both programs have limitations--the technical assistance is very limited in scope and focus and the Best Practices and minimum staffing requirements have been underway for just one year. The programs, however, include distinct features in their development and continuing processes that distinguish them from other states and which could serve as valuable models to other states. The technical assistance program involves one nurse providing behavioral consultation statewide to any long-term facility upon request. Its success in improving resident outcomes through a combination of consultative and educational support is apparent, although not formally proven. On a small scale it demonstrates the value of an individual facility/resident approach, the need to involve all staff in care planning and problem solving, and the benefits of distancing technical assistance from enforcement activities and of providing education that is tailored to the direct care staff. Although only two Best Practices workshops have been presented, one of them utilized a unique approach of incorporating information on regulatory compliance with practical implementation guidance. A surveyor provided interpretation of regulations followed by a panel discussion/presentations by facilities that had submitted best practices around a particular clinical area. This combination of reporting enforcement interpretation and successful clinical outcomes captured the attention and interest of administration and clinical staff with subsequent changes in policy and care planning. Lastly, the manner in which the legislation covering the quality improvement programs was written was an attempt by the legislature to first identify guiding principles and goals and then use them to develop a targeted approach to accomplish the goals, rather than reacting to isolated issues. The development of a framework for how the Maine long-term care system should operate and the identification of key principles to guide public policy decisions on long-term care was seen as a novel approach. It remains to be seen how and to what degree these principles will impact future long-term care legislation. ReferencesAHCA. State Summaries of Nursing Facilities, 2001/www.ahca.org/research/keynotes/statefactsheets-2001.pdf. State of Maine Public Law 49, Chapter 731, Part BBBB, Sections BBBB-1 through BBBB-16, Signed April 25, 2000. State of Maine, 119th Legislature, Second Regular Session, "Long Term Care in Maine--A Progress Report." Joint Standing Committee on Health and Human Services, January 2000. State of Maine, "Long Term Care Status Report, Bureau of Elder and Adult Services, December 2002. (http://www.state.me.us/dhs/beas/ltc/2002/ltc_2002.htm#nursing). MarylandOverview of the Maryland Site VisitThis report describes findings from our exploration of the State of Maryland's quality improvement projects (QIPs). We first present some background information about Maryland and about the project team's site visit to that state. Next, a history and rationale for Maryland's movement toward state-initiated quality improvement is presented. This is followed by a description of each program reviewed by the project team. Findings regarding the strengths and weaknesses (as identified by state and nursing home industry representatives) are presented, as is a discussion of the impact of the QIPs on quality of care and quality of life of nursing facility residents. Finally, lessons learned by the state are presented, along with a brief description of the perceived sustainability of the various QIPs. A Brief Description of Maryland's Nursing Home IndustryTo put Maryland in context with other health care environments around the country, and with others studied here, we describe several characteristics of the state's nursing home environment. Comparative data presented are from the AHCA web site (AHCA, 2002). Maryland facilities are slightly larger than those in the rest of the country, with an average of 121 beds per facility (vs. 108). Fewer of Maryland's facilities are for-profit (57 percent vs. 65 percent), 13 percent are hospital-based, and 50 percent are chain-owned. There are a total of 262 facilities in the State, the majority of which (89.7 percent) are dually certified for Medicare and Medicaid. Impetus for QIPsThe impetus for the enactment of the Maryland quality improvement programs in 2000 as explained by the provider associations and the survey agency appears to have been based on a series of events and activities that occurred both within and outside the state in the preceding ten years. Beginning in 1989, deplorable conditions existing in a Maryland facility were reported in the media, which led (over the next three years) to multiple nursing facility closures. In 1997, findings from the California study of death certificates were published in Time Magazine. This led to a U.S. General Accounting Office (GAO) investigation in 1998 on California nursing homes (USGAO, 1998) and in 1999 on federal and state complaint and enforcement practices (USGAO, 1999). The 1999 GAO study noted problems with Maryland's complaint investigations, stating that the process was too slow. That same year, negative personal experiences by several influential state senators in Maryland nursing homes, along with damaging testimony before the legislature by OHCQ staff on the issue of complaints, pressed the legislature to tie the passage of a nursing home funding bill to the creation of a Nursing Home Task Force to study quality and oversight in Maryland. The for-profit provider association explained to the project team that their primary concern at that time was the restoration of full Medicaid funding that was promised in the bill. Although both provider associations indicated that they did not agree with the proposed member composition of the Task Force, specifically that stakeholders were included only on subcommittees, they were compelled to support the bill to ensure funding. The Task Force began meeting during the summer of 1999 and presented their recommendations in January 2000. The Task Force identified the following:
In May 2000 a broad Nursing Home Reform Package was introduced containing six bills covering the following areas:
Carol Benner explained that the six bills, which she wrote, represented a "six prong approach to improve quality." She stated that the general approach in the past had been to strengthen regulations and sanctions to weed out the bad providers, but that there had been no provisions to address quality. According to Benner, at the heart of the bills was the quality improvement program. HFAM reported that the key aspect of the legislation had to do with Medicaid funding for additional staffing and benefits. Within each specific bill, there were components that the various stakeholders pushed to modify; however, no bill was defeated in its entirety. One provider explained that members of the Task Force agreed on the principles of the reform but differed on the operationalization of reforms and the timing for implementation. For example, Benner had proposed that the quality improvement programs in each facility be lead by a full-time nurse. Due to opposition by HFAM, this was modified to remove the requirement of a nurse. The legislature had initially promoted four surveys per year while the survey agency and provider groups were satisfied with two surveys. The final bill passed called for two nursing home surveys per year. Overall Intent/Vision for QIPsComments from the provider associations and the survey agency, and the language of the legislature, all differ in the emphasis that they place on the various components of the quality improvement programs. There were clearly additional regulations introduced to strengthen the survey agency's oversight and ability to sanction; at the same time, provisions were added for greater consumer advocacy and technical assistance. The language in the proposed legislation stated that the bills were drafted because it had become clear to everyone that the nursing home industry needed significant reform to improve the quality of life for residents. The proposal was aimed at strengthening state regulations in areas where the applicable federal standard was not sufficient to protect the public health, safety or welfare of Maryland citizens. The proposal identifies areas that federal regulations either do not address or are deemed to be too weak. Federal regulations do not address the relocation of residents or appropriate procedures to minimize relocation trauma, nor do they address the posting of staffing ratios and staff assignments, which Maryland legislators wanted to see defined. Federal regulations for quality assurance were also seen as deficient, not going far enough in terms of defining the framework for an acceptable quality improvement program. According to Carol Benner, the purpose of the nursing home reform was to "give [the state] effective tools to gain and sustain compliance in Maryland homes." She noted a need to change the culture of both surveyors and nursing facility staff to focus on quality and resident safety, as opposed to regulation and enforcement. She also stated that, "although the survey agency seems to be effective at removing poor performing nursing homes from the system, there is no evidence that the current survey process is effective at improving quality. In fact, little is known about what does improve quality in nursing homes. To improve quality, Maryland is trying a variety of efforts." In one presentation she stated, "We decided to do anything that worked to improve quality--the 'throw the spaghetti at the refrigerator and see what sticks' approach." Description of State-Initiated Quality Improvement Programs in MarylandThe quality improvement programs that were initiated by legislation passed in the Maryland General Assembly are described in detail below. They are followed by a description of programs initiated by OHCQ, subsequent to the passage of the Maryland Nursing Home Reform Act, in an effort to improve nursing home performance. Aspects of QIPs that were Noted to Work WellBoth the QA Plan requirement and the Second Survey were noted by those we spoke with to be positive aspects of the Maryland quality initiatives. Comments regarding the QA Plan were that a requirement that "formalized" quality assurance was good, and encouraged providers to look at whether they had a comprehensive enough approach. One provider stated that the "formalized approach" to QA makes them stay attuned to issues, in a way they may not without a formal requirement. A facility representative believed that the requirement to meet and review QA activities monthly is positive because it "makes the QA program more meaningful" and helped to give nursing home administrators and management a better understanding of quality issues. Another provider stated that having the quality improvement programs as a focus allows facility nurses to feel empowered, and gives them the perspective that they can have an effect on their environment. This is a great enhancement over the former feeling that the best they could do in terms of performance was score a "zero" on their number of deficiency citations. Finally, the Ombudsmen stated that the process of the facility sitting down and talking with the medical director and each other during the QA meeting has had a very positive effect, and that the QA requirement has made facilities more aware and more accountable. The Second Survey was seen as a positive aspect of Maryland's quality improvement initiatives. HFAM believes the second survey program is a positive change, and the sharing of best practice information is positive. One facility reported that the second survey was a welcome relief after the state LTC certification survey ("during certification surveys we were grilled, exhausted and I felt kicked"). This group stated that it is a relief to be able to have an open dialogue about problems and issues in resident care, and to obtain advise and feedback. Although there was initially a great deal of suspicion, those we spoke with stated that the Second Survey has changed the relationship between the State and providers and has enabled providers to identify problems and implement corrections. Other general comments regarding what seems to work well in Maryland had to do with the use of quality indicators in the second survey and in other quality initiatives, and the more positive relationship between the state and the provider community. HFAM noted that the new focus on quality indicators and quality improvement was a good outcome of the QA requirements, and that the focus no longer revolves simply around deficiencies. The Ombudsmen stated that the relationship between the state and providers had improved since the implementation of the quality improvement initiatives. OHCQ is perceived as having attempted to make the survey process less adversarial. Ombudsmen report fewer complaints from facilities about the LTC certification surveys than previously. Additional positive observations made by providers included the following:
Aspects of QIPs that were Noted to be Less SuccessfulThe central themes regarding aspects of the Maryland quality initiatives that were less successful were around communication of quality initiatives with the Ombudsman, provider access to funding, and the minimum staffing requirement. With the exception of one person we spoke with (a supervisor), Ombudsman were not at all familiar with the Second Survey, and wished that they were more informed about this. In general, ombudsmen were unaware of or at least personally unfamiliar with two other initiatives: the clinical alerts and the decubitus ulcer project. They also objected to facilities' inconsistent approach to communicating with them regarding QA meetings and QA activities. All received different levels of communication from their facilities regarding the QA meetings, some inconsistently received meeting minutes, and all wished to be kept abreast of QA activities on a regular basis. HFAM believes that the health quality account could be more accessible (argues that state has $2 million in CMP monies that they should be able to access for QIPs). Lifespan agreed that more money needed to be made available for quality improvement projects such as WellSpring (Lifespan has applied for grant money from state, but still awaiting approval and funding). In terms of the staffing requirements, two main areas of program weakness were noted. Ombudsman stated that--despite the facilities' seeming compliance with the posting of staff mandate--facilities often post the number of staff that were on the schedule, not necessarily those that actually reported for work or are actually working on that particular unit. Also some facilities posted the information, but not always in a visible location. This can be confusing for family members. With regard to the minimum staffing requirement, most providers we spoke to believe this requirement to be unnecessary, as the levels required were described as "the bare minimum" and claimed that most facilities staff well above those minimums. One comment was made regarding potential improvements to the Quality Indicator Study. The state reported that many nursing facilities had unrealistic expectations regarding their expected performance on quality indicators. For example, some facilities may have set goals to have a zero percent QI rate, rather than simply attempting to decrease the rate by a certain percentage. Improved understanding of this issue will be required in order to assist providers in attaining quality improvement goals. The state has begun to conduct an evaluation of this program by looking at baseline data and follow up rates of the three targeted quality indicators. Another comment was made about the medical director requirement, which was that medical directors are concerned that they do not have enough time to fulfill their responsibilities. For this reason, some questioned the ability of this regulation to have any impact. Impact of QIPs on Quality of Care and Quality of LifeAspects of the QA Plan requirement were seen as having a positive impact on quality of care, and one HFAM representative believed that - though it's too soon to tell if the Medical Director requirements will have an affect on quality--this requirement has the potential to have a positive effect. Those who believed that quality of care were positively influenced by the QA requirement made the following observations:
HFAM stated that the regulations may have merely "fine-tuned" programs already in place intended to enhance quality. Providers believe that the focus on quality improvement and QIs, combined with the Second Survey, has actually worked to improve quality. A potential negative impact on resident quality of life was cited by the Ombudsmen as being attributable to the QA requirements. Some facilities have reportedly initiated "Grand body rounds" or "full body checks" in response to need for QA and daily monitoring. This process involves a team (of three staff) rounding on all patients and inspecting their skin (at times including genitalia). The Ombudsmen consider this a violation of patient rights and of privacy, and believe that facilities have begun the practice in response to the QA requirements. While perceived to have a positive effect, the true effectiveness of the Maryland quality improvement initiatives has not yet been measured. The next phase, per the state, is to evaluate the effectiveness of the programs. According to OHCQ, the eventual evaluation will look at complaint rates, correlations between deficiency citations and areas targeted for facility quality improvement, and facility satisfaction with the Second Survey. Sustainability and Lessons LearnedThere was no discussion among those we spoke to of any of the nursing home reform legislation being repealed, or any quality initiatives being at risk of termination due to budget cuts or other reasons. This lack of discussion or concern, combined with a generally positive attitude among the provider community about the quality initiatives, indicate that most Maryland QIPs appear quite sustainable. Carol Benner reported that most programs are of cost to providers (vs. the state), and that the Second Survey is likely to continue. "The Second Survey people are protected…they aren't federally funded…". There were many lessons learned cited by the state staff, and a couple of comments made regarding how the quality initiatives could have been better implemented. A provider stated that the state could have moved more slowly in implementing regulations, as facilities were not adequately prepared for newly required QA activities. General lessons learned by OHCQ staff in Maryland include:
Program-specific comments had to do with the Medical Director requirement and the implementation of the Second Survey. In terms of the Medical Director requirement, the state reported that, if they had to do this all again, they probably would have engaged in more collaboration with the industry and physician groups to get buy-in from these groups before the Medical Director regulation went into effect. They would, however, advise other states to follow their lead and pass strong regulations to make physicians accountable. Lessons learned regarding the Second Survey included that, since a process like this is a dramatic departure from the usual "surveyor" mindset, the personality of the technical assistance surveyors is the key to success. The surveyors themselves commented that it is very important early in implementation to assure that everyone involved in the program "be on the same page." They found that, early on in the process, they were not always consistent in their message to facilities. This has improved over time, but could have been dealt with more effectively by more thorough communication. The Second Survey is evolving with time and as lessons are learned by the surveyors. For example, a standardized tool has been developed for the Second Survey that examines the facility's ability to internally monitor falls, malnutrition and dehydration, pressure ulcers, medication administration, accidents and injuries, changes in physical/mental status, quality indicators, and other important aspects of care. At the time of our visit, all nursing homes had been surveyed once and baseline data had been collected. The Technical Assistance Unit is in the process of reviewing lessons learned from the first year and establishing the focus for the second round of surveys. Potential Role of the Federal Government in Quality Improvement and Barriers to Quality Imposed by the Federal GovernmentComments on the role of the Federal Government in promoting quality improvement were quite limited. One facility administrator stated that she saw the Federal Government's role focused on data collection, but that the states should be taking the lead on quality improvement programs. The corporate vice president for clinical services stated that she wasn't certain exactly what the role of the Federal Government should be, but that their involvement was critical, primarily because of their responsibility for funding. She noted several possible areas for the Federal Government involvement--data management, producing national trends, and disseminating best practices. She felt that an effort to maximize the utility and applicability of the data to multiple agencies and organizations was important. Summary/ConclusionsThe project team was impressed with the level of support that most QIPs received from the various providers that participated in our discussions. The general attitude expressed was that most of the QIPs introduced in the Nursing Home Reform package were feasible, appropriately directed, and able to be implemented by most (if not all) nursing facilities. Some areas for improvement were noted, of course, but by and large those we spoke to were supportive of the programs. Areas noted for improvement were an increase in communication about QIPs between OHCQ and the Ombudsmen and between facilities and the Ombudsmen, and a greater degree of accessibility among providers to special funds for quality improvement projects. This is not to say that all nursing facility representatives with whom we met in Maryland believed strongly in the ability of the programs to improve resident outcomes. To the contrary, providers were skeptical that these QIPs were sufficient to solve the quality of care problem in nursing homes. They named issues of staffing and of the long-term care survey and certification process as barriers to high quality performance. Providers attributed the biggest problems to promoting or increasing nursing home quality to:
Provider representatives met with also stated that the long-term care survey and certification requirements must be changed, as the process and penalties are so severe that it is impossible for facilities to ever feel positive about performance when the best result that can stem from the long-term care survey is a "zero" deficiency. Another opinion expressed in general about the quality initiatives was with regard to quality indicators used for measuring facility performance. The opinion was expressed that quality indicators should focus on positive outcomes, rather than just on negative measures. An example of a positive indicator of quality cited was the number of hours the Medical Director is in the facility. From this project's point of view, it is difficult to say with certainty what will work in Maryland and what may not work to improve nursing home quality. There are a multitude of initiatives underway, all enacted during the same timeframe, all enacted in a climate of decreases in nurse staffing and other changes affecting the nursing home industry (e.g., declines in occupancy, Medicare skilled nursing facility prospective payment, public reporting MDS-based quality indicators). No formal evaluation is currently underway to examine the affect of any of these programs on resident outcomes. Such an evaluation would assist the state in refining and improving upon the current set of quality initiatives. ReferencesAHCA. State Summaries of Nursing Facilities, 2001. www.ahca.org/research/keynotes/statefactsheets-2001.pdf. Time Magazine. Fatal Neglect: In possible thousands of cases, nursing home residents are dying from a lack of food and water and the most basic level of hygiene. October 27, 1997. U.S. General Accounting Office. California Nursing Homes: Care Problems Persist Despite Federal and State Oversight. HEHS-98-202. July 27, 1998. U.S. General Accounting Office. Nursing Homes: Stronger Complaint and Enforcement Practices Needed to Better Ensure Adequate Care. T-HEHS-99-89. March 22, 1999. MissouriOverview of the Missouri VisitMissouri was selected for a state site visit because of the project team's interest in the quality improvement projects that have been implemented in the state by Marilyn Rantz and her colleagues at the University of Missouri-Columbia Sinclair School of Nursing. They have developed and implemented the following quality improvement programs in the state: the Missouri "Show-Me Quality Indicator Report" (implemented in 1999), the Quality Improvement Program for Missouri (QIPMO) (pilot tested in 1999 and implemented in 2000), a staff education program for the state's surveyors (which started in the early 1990s), a support group for MDS coordinators (which started in 2001), and a nursing home staff education program (which started in 1997). They think of these as various components of a single quality improvement effort rather than separate programs. Missouri is the only state with this type of partnership between the state survey agency and a university. The QIPMO program includes on-site technical assistance, educational programs and support groups for facility staff and an educational component for survey agency staff. A Best Practices program is also funded by the state and run by Central Missouri University. A Brief Description of Missouri's Nursing Home IndustryIn order to compare Missouri's nursing home industry with the other study states, we present some descriptive characteristics. There are 552 facilities in Missouri (AHCA web site) with 38,671 residents reported as of Spring 2001. The average number of beds per facility is 99, which is slightly lower than the national average of 108. Missouri's average occupancy rate for its nursing homes (80 percent) is one of the lowest in the nation as reported by the Missouri auditor (2001). The median occupancy rate per facility is 75.9 percent as compared to the national rate of 95.1 percent. The percentage of for profit and not for profit homes in Missouri is very close to the national averages with 67 percent of Missouri homes operating for profit (vs. 65 percent national average) and 24 percent as non-profit homes (vs. 28 percent national average). There are slightly more homes government operated (9 percent vs. 7 percent). The state has a below-average percentage of chain-affiliated facilities (48 percent vs. the national average of 55 percent). Twelve percent of the state's nursing facilities are hospital-based, which is the same as the national average. The majority of homes are dually certified for Medicare and Medicaid (75 percent) as compared to the national average of 80 percent. Impetus for Missouri's Quality Improvement ProgramsThe QIPMO programs originated from the vision of Marilyn Rantz and supporters at the Division of Aging. Dr. Rantz holds a Ph.D. in Nursing from the University of Wisconsin-Milwaukee, Masters of Science in Nursing from Marquette University, and Master of Arts in Teaching from the University of Wisconsin-Whitewater. She has also been a nursing home administrator. While at Wisconsin, she worked under David Zimmerman and provided clinical input to the development of the CHSRA quality indicators. Dr. Rantz was interested in using MDS data to track nursing home quality and came to the University of Missouri because she would have access to MDS data. Dr. Rantz worked with Paul Shumate, who was then the Director of Long-Term Care Regulation to introduce quality improvement programs. He was interested in seeing that the MDS data be used and improved. She began in 1993 to put the research team together. A statute establishing the Nursing Facility Quality of Care Fund was introduced in 1994 and made effective in 1995. According to a staff member at the Missouri QIO who had been employed in the survey agency for over 20 years, at the time the Quality of Care Fund was introduced, there had been a great deal of tension between facilities and the Division of Aging. The proposal was introduced as a way to use the nursing home fines to fund quality improvement programs--a way to utilize the fines to prevent future fines. The survey agency accepted the proposition because it provided some assistance for facilities in a manner that did not compromise their role in regulatory enforcement. The statue required that any activities funded under this statute had to be approved by both provider associations. In 1999, the University ran the pilot study testing the impact of using advanced practice nurses to provide technical assistance to nursing facilities. When the pilot demonstrated that on-going on-site visits were effective in improving resident outcomes, Paul Shumate wanted to expand the program to include all nursing facilities. Around the same time, the state auditor reported that the state was behind on their surveys. Missouri requires an annual certification and licensure survey as well as a briefer interim survey. The AHCA affiliate director did not believe that facilities would accept QIPMO visits without some sort of incentive. He promoted the idea of using the QIPMO visit as the interim survey. As Dr. Rantz explained, she was not in favor of this, as she believed the focus of QIPMO visits should be on quality and did not like being this closely linked to the survey process. Resident advocates feared that the change would weaken enforcement mechanisms. Ombudsman and resident advocates agreed with Dr. Rantz on this. However, in an effort to get the program implemented, she went along with the proposal hoping that the process could later be revised. Linkage to the interim survey lasted only about six months--a regulation was passed requiring that all surveys be unannounced and because QIPMO visits were scheduled in advance with facilities, QIPMO visits could no longer take the place of interim surveys. Recent changes in the organization of the Division of Aging also appear to have had at least some indirect effect on quality improvement programs. During Governor Carnahan's tenure, there had been an attempt to pass a constitutional amendment to create a separate Department of Aging. This was defeated however, in a statewide referendum. After Carnahan's death in October 2000, the acting governor moved the Division of Aging to the Department of Health and Senior Services by means of an executive order. The intent was to focus more attention on aging issues by moving it into a smaller department (the Department of Social Services had at the time over 10,000 employees). According to informants, the move took approximately one year to organize and had just recently been completed. As part of the transition, the Institutional Services Section of the former Division of Aging became the Section for Long Term Care Regulation under the Division of Health Standards and Licensure within the Department of Health and Senior Services. During our discussions with stakeholders, and in subsequent correspondence with state survey agency personnel, we received differing opinions of the effect of the reorganization. According to some we spoke to, during the reorganization, there has been significant turnover and staff changes at both the surveyor and management levels, with a resultant loss of much "history" and institutional knowledge, particularly related to QIPMO. David Morgan, Manager of the state's Section for Long-Term Care Regulation, stated that there has not been a great deal of turnover in response to the reorganization. He also notes that the changes that have occurred have given the agency "new perspectives that may find other issues with programs prior staff were blind to." Concern was also voiced that changes that have occurred as a result of the reorganization have strained the ability of the Section for Long Term Care Regulation to operate effectively, and that the agency is not able to target poorly performing facilities as aggressively as it had previously. However, recent audits have identified several areas of improvement in the management and performance of the state's survey agency. The number of facilities receiving notices of non-compliance has remained stable, and it is not clear whether the reorganization has impacted the effectiveness of the state's survey and certification activities. Regardless of whether the organizational changes have been beneficial or deleterious overall, many stakeholders expressed the concern that the changes, coupled with the state's budget crisis and the new nursing home quality initiatives launched by the state's QIO, have created a tenuous situation for continued QIPMO funding. Dr. Rantz was able to use her analyses of the effectiveness of QIPMO to secure funding for this year, convincing the state that the program is effective in improving nursing home quality and a prudent funding choice in an atmosphere of competing agency needs. Overall Intent/Vision for Missouri's Quality Improvement ProgramsMarilyn Rantz states that the guiding principle of QIPMO is that "things can be done differently." She explains that much of the care provided in nursing homes is routine and is provided the way it is simply because "it's always been done that way." The QIPMO nurses challenge facilities to think about care planning differently and to make changes in how care is provided to improve quality of care. The program is focused on raising standards of care for the elderly by helping the facility to identify and solve their care problems. QIPMO nurses use the quality indicator reports for quality improvement, not survey improvement. The survey process is focused on meeting minimum regulatory standards, but QIPMO is focused on best practices and applying the current care guidelines to achieve something beyond minimal outcomes. Dr. Rantz believes that if standard care practices are met, it is likely that the facility will not have problems with the survey process. Description of Quality Improvement Programs in MissouriThe Missouri Quality Improvement Program for Missouri (QIPMO) is an on-site clinical consultation program intended to assist nursing homes with their quality improvement programs. There are several distinctive features of the QIPMO program:
The QIPMO program includes several integral components:
The state also has a Best Practices program administered through the Central Missouri State University. "Show-Me" Quality Indicator Reports Electronic longitudinal "Show-Me" Quality Indicator Reports are compiled each quarter and available on-line via the statewide computer network for all nursing facilities in the state. These reports show how each facility is performing over the past five quarters for each CHSRA quality indicator in comparison to statewide tenth percentile thresholds. The reports were developed by Marilyn Rantz and colleagues and are used by the QIPMO nurses to structure and guide the on-site technical assistance visit. The "Show-Me" Quality Indicator Report consists of the CHSRA quality indicator trend graphs and summary tables, displayed one indicator per page, along with a resident roster listing each resident with the quality indicator(s) that they trigger. The summary table contains by quarter, the facility's QI score, number of residents with the QI, number of residents included in the calculation, number of residents not in the calculation, the applicable MDS items and the statewide summary. Statewide summary includes the tenth percentile score and the facility's ranking in Missouri. Each page also includes a definition of the indicator and explanation of the upper and lower thresholds. Appendix Bcontains a sample "Show Me" report. On-Site Clinical Consultation Visits Beginning in mid-2000, specially trained QIPMO nurses have conducted technical assistance visits at nursing facilities, residential and intermediate care facilities. These visits are voluntary, consultative, confidential and intended to assist nursing homes with their quality improvement programs. The technical assistance component to QIPMO was pilot tested with 113 facilities in 1999. Results of the pilot indicated that on-going on-site clinical consultation by an advanced practice nurse was effective in improving care and outcomes for residents in nursing facilities. Each visit is facility-specific and begins with a review of the facility's "Show-Me" Quality Indicator Reports. After an understanding of the QI definitions and reports is achieved, QIPMO visits often result in the identification of specific clinical indicators that may need further review. Facility staff are guided through the process to determine whether the QI result is an accurate representation of their residents, beginning with a check of the accuracy of the MDS item coding and progressing to a review of facility care processes in terms of their ability to meet accepted clinical standards. Using the resident roster generated as part of the "Show-Me" reports, QIPMO nurses use actual facility residents to focus discussion on MDS accuracy and resident-specific care processes. There is no charge associated with the visit. In the course of a QIPMO visit, depending on the needs of the facility, the clinical team may conduct group discussions with members of the nursing care team including nursing assistants, observe care processes, review medical records and provide in-service programs on a variety of MDS-and clinical care-related topics. Standardization of MDS Education Recognizing that accurate QI reports would provide the foundation for quality improvement efforts and that accurate MDS assessment data was critical to valid QI reports, University of Missouri faculty partnered with the Missouri Division of Aging to convene a group of industry representatives to guide the on-going state needs for staff education on the MDS. The group included representatives from the Missouri Health Care Association, the Missouri Hospital Association, the Missouri Association for Homes and Services for the Aging and the Missouri League of Nursing Home Administrators. Their goal was to provide consistent and accurate information on the MDS and use the MDS data for quality improvement. The group began meeting in March 1997 and continues to meet on a quarterly basis. In the first year, they developed standardized educational materials on the MDS which are currently required to be used by any individual or organization providing MDS education in the state. Training materials consist of an "Item-by-Item Guide to the MDS" and a "Case Study: Mrs. M." The Item-By-Item Guide is a reference for correct coding and definitions of MDS items. The Case Study is used for teaching the Resident Assessment Protocols and care planning. They are intended for use with the interdisciplinary team and not just for nursing staff. Workshops are provided several times a year at varied locations throughout the state. Monthly Support Groups for MDS Coordinators As they conducted their technical assistance visits, QIPMO nurses became increasingly aware of the high turnover of MDS Coordinators. Believing that the turnover was related to a lack of resources, a lack of support, lack of understanding of their role by administrative staff and co-workers and feelings of stress in their positions, the QIPMO nurses initiated monthly support group meetings in May 2000 in the St. Louis area. Since then, monthly meetings have expanded to the seven geographic regions of the state covered by the seven QIPMO nurses. The support group goals include: (1) Improve MDS coding accuracy, (2) Enhance job satisfaction for MDS Coordinators, and (3) Increase overall staff retention rates. Meetings are facilitated by QIPMO nurses and are held at volunteer facilities in each region. There is no charge for the meeting, with expenses for mailings covered by the host facility. QIPMO nurses schedule the meetings, select topics or speakers and serve as resources. Meeting formats vary based on the interests and concerns of the group, and problem solving occurs collaboratively. The state regulatory agency, particularly the state MDS coordinator, has been supportive of the group and has visited each region to give the participants the opportunity to ask questions. State technical support staff have also attended meetings, as have regional surveyors. Surveyor Training, Provider Meeting Participation and other Educational Programming QIPMO nurses participate in educational programs for state surveyors, providing both annual statewide training and regional training that focuses on clinical topics and the MDS/RAI process. The goal is to provide education for surveyors that is consistent with the information presented to nursing home staff as part of QIPMO. QIPMO nurses also participate in statewide provider meetings conducted and sponsored by the Division of Aging. In 2000 and 2001, provider meetings were held in various cities throughout the state. There was a one-day session sponsored by the Department of Health and Senior Services (DHSS) in which information about the regulatory process was discussed. At the meeting, which was attended by several hundred providers, the QIPMO nurses spoke about their program, which is strongly endorsed by DHSS staff. Best Practices Program The Best Practices Program is administered by Central Missouri State University and is unaffiliated with the state survey agency, although it is supported by state funds. A statewide committee, which includes seven representatives from each of the two provider associations and several staff from the state Ombudsman's office, reviews applications from facilities. The committee determines the topics and solicits applications. Thirty facility practices were nominated in 2001. These nominated practices are published and disseminated by the university. Until last year (when there was no conference), award winners were recognized at the Governor's Conference on Aging. Aspects of Missouri's Quality Improvement Programs Noted to Work WellMost of the stakeholders contacted believed that the program as a whole was very beneficial. Feedback from providers that is collected on evaluation forms following technical assistance visits by the QIPMO nurses was overwhelmingly positive. A facility director of nursing expressed that "QIPMO visits are free, not punitive, supportive and encouraging." QIPMO visits have been available since mid-2000 and current facility participation runs around 45 percent. Monthly support groups, initiated in May 2000, seem to be instrumental in introducing the QIPMO nurses to the community, providing education and networking support for the MDS Coordinators and at the same time indirectly promoting the program. The fact that the quality improvement activities operate separately from the survey activities and that each entity favors and respects the separation was seen as a positive aspect of the program. Surveyors appear to defer to QIPMO nurses on clinical issues, while the QIPMO nurses do not get involved in enforcement/regulatory issues. The survey agency has taken a strong stance in maintaining their role as monitors and regulators and distancing themselves from any consultative role. The strong leadership and vision of Marilyn Rantz is seen as another positive aspect to the program. Others were impressed by her knowledge of issues related to quality of care in nursing homes and her research skills, as well as her passion for improving quality and her determination in obtaining support for quality improvement programs. She has had to use all of these qualities to successfully implement QIPMO in Missouri. Her experience having worked under David Zimmerman and her familiarity with the CHSRA QIs along with her employment as a nursing home administrator for a 400-bed county home prepared her both as a quality expert and as someone experienced in dealing with the politics sometimes necessary to achieve one's goals. Her strong background in education has been critical to the development and structure of QIPMO and to the training of the QIPMO nurses. The fact that the QIPMO program is research based puts the program ahead in other states in terms of evaluation and demonstrated effectiveness. The technical assistance visits grew out of a pilot program that demonstrated the effectiveness of on-going, on-site visits by advanced practice nurses on resident outcomes. Dr. Rantz and her colleagues have completed numerous studies on the impact of QIPMO on nursing home residents as measured by the CHSRA quality indicators. Aspects of Missouri's Quality Improvement Programs Noted to be Less SuccessfulAlthough the feedback from facilities on the value and effectiveness of the various aspects of the QIPMO program was very positive, it was reported that less than half (45 percent) of Missouri facilities take advantage of the free program. When questioned as to reasons for non-participation, those we spoke with stated that facilities that were part of a chain sometimes felt that those types of supportive services were already being provided for them. Other reasons offered were that facilities were either not aware of the program, did not understand it, did not trust that there was no connection to the survey agency or did not see the value. There was evidence that some providers, particularly those associated with the for-profit association, did not understand the program. Some of the confusion seemed to result from the early days of the program when QIPMO was used as a substitute for the interim survey that Missouri facilities receive six months after the regular survey. This was a short-lived experiment that was not supported by Marilyn Rantz and which everyone agrees did not work well. For these providers, doing well on their survey was their measure of quality and their primary focus. If QIPMO visits did not help them prepare for and accomplish a good survey, they could not see the value of participating. Furthermore, in the early days of the program when the QIPMO visit could substitute for an interim survey, there were situations in which facilities may have had a productive QIPMO visit, but then received multiple deficiency citations on their next survey, primarily because the QIPMO nurses were not trained in the state regulations and did not provide any counseling around those issues. Some participants suggested that facilities are not aware that the program exists, despite efforts to publicize the program, given high turnover among directors of nursing and administrators. Also, because the program was initially associated with the survey process, some facilities do not realize (or believe) that QIPMO is totally separate from the survey agency and does not report its findings to the survey agency. Some facilities are hesitant to allow outsiders into their buildings to review records and observe care. There were also comments that facilities were uncertain as to how to schedule a visit, believing that facilities were made "to jump through hoops" and had to make requests for QIPMO visits in writing. A few facilities regard QIPMO as a program that "just means more work" for facilities. Given that the program is voluntary, it is likely that QIPMO is not reaching facilities with very poor performance. Such facilities may have little reserves to take on a new project when faced with the day-to-day struggles to keep a facility running, lacking the staff and infrastructure necessary for the QIPMO nurses to work with. The QIO representative who had worked with some of the QIPMO materials felt that some of their forms were too academic and involved for the average facility. She reported taking their fall investigation form and shortening it from four pages to two to make it a more user-friendly. Impact of Missouri's Quality Improvement Programs on Quality of Care/Quality of LifeMissouri is far ahead of other states in terms of evaluating the impact of its quality improvement programs. Dr. Rantz uses MDS data to measure the change in quality indicators associated with the program and has published several journal articles that report these results. In addition, facilities that receive QIPMO visits provide feedback through an evaluation form that they are given at the end of each visit. Analysis of MDS data, suggests that even poor performers are doing better, either due to QIPMO or other changes that have occurred in the past few years. QIPMO nurses are noting increased levels of MDS understanding and more sophisticated questions, suggesting that the information offered in the support groups is having a positive effect. Participants in the meetings find them to be an extremely valuable resource--a common theme is that knowing that they are not the only one facing particular issues is a major help. One coordinator said that if "they had this kind of support at my last job, they wouldn't have taken me out of the facility on a stretcher with oxygen." The MDS Coordinator at one nursing home the researchers visited participates in the support groups, which she describes as being "very helpful." Since the implementation of QIPMO, there have been improvements in 16 quality indicators and a decline in only six measures. In addition to analyzing median quality indicator scores, the research team analyzes trends for the 90th and 95th percentile, so that the effectiveness of the program in improving outcomes for low-quality facilities can be understood. Improvement in the following measures has been noted:
(Note that, as a researcher grounded in solid evaluation skills, Dr. Rantz has not compared outcomes for QIPMO participants vs. non-participants, although the state is now asking her to do this. Such a comparison would confound programmatic effects vs. selection effects, due to the non-random selection of facilities into QIPMO.) Several quality indicators have gotten worse in Missouri since the implementation of QIPMO, including behavior problems for high-risk residents, patients receiving nine or more medications, range of motion training/practice, and antipsychotics use in the absence of an appropriate diagnosis. Preliminary investigations suggest that these declines may reflect MDS coding issues rather than actual decline of care. Sustainability and Lessons LearnedQIPMO faces an uncertain future and during our visit Dr. Rantz had voiced serious concerns about the program's chances for survival. The transition of the survey agency into the Department of Health with the resulting loss in staff that had previously supported the program coupled with the QIO initiative has created an uncertain situation. Rantz stated that it had been difficult to keep the funding this year as the new survey agency staff needed to be convinced that funding for QIPMO was preferable to hiring more surveyors. She was able to demonstrate some of the good outcomes associated with QIPMO and by working with a few supportive legislators, was able to save the program this year. The new QIO initiative is similar to QIPMO in that it also involves the provision of technical assistance to nursing facilities targeting certain quality indicators for improvement. As the QIO effort got underway, there was concern that the state would see the two programs as duplicative and decide not to continue funding QIPMO. At the time of our visit, the Missouri QIO with whom we had met several times was eager to work with QIPMO and design their programs to complement, not duplicate QIPMO. But, an obvious question that arose was if the state can get the Federal Government to pay for its quality improvement program through the QIO, why then should they also pay for QIPMO? Dr. Rantz stated almost regretfully that she had "helped light the fire" of the QIO program by demonstrating that facility outcomes can be improved through on-site visits and at a relatively small cost. In a follow-up conversation with Dr. Rantz in November 2002, she indicated that a subcontract for QIPMO nurses to do on-site visits and provide technical assistance to nursing facilities within the QIO scope of work had been successfully negotiated with the QIO and approved by CMS. Dr. Rantz is pleased to collaborate with the QIO as it appears that the QIO work will enhance and not duplicate QIPMO work with facilities. Marilyn Rantz pointed out that for a program to demonstrate effectiveness, it must be data driven. Data must be presented in a format that is understandable to facility staff and education must be provided around the concept of quality and goal setting. Facilities are too often satisfied with just average performance. Data must assist users to identify the specific residents involved and show changes over time. Role of the Federal Government in Quality ImprovementMarilyn Rantz believes that the Federal Government should support and expand programs like QIPMO into other states. The partnership between the university and the Department of Health and Senior Services could serve as a model for other states. She also believes that the partnership could be expanded to include the state QIO as well as the state survey agency and an academic institution with a strong clinical focus on gerontology. Together these groups may be able to bring about the necessary changes in facility practices to achieve the desired level of quality. The current involvement of the QIOs in providing technical assistance to nursing facilities concerns Dr Rantz as she fears that CMS' interest in this initiative will not be sustained and that in a few years they may change their focus and direct their efforts and funding elsewhere. Dr. Rantz would like to see the "Show-Me" Quality Indicator Reports made available to all states and made a formal request to CMS that the CHSRA QIs be expanded to include "Show-Me" reports. She also shared information on the "Show-Me" Reports with the QIOs as an option to include in their programs. Provider representatives that we spoke with were harsh in their criticism of the Federal Government. The relationship between the state and federal agency was described as being "hostile" and "out of hand," and providers urged the Federal Government to "get off the state's back." Providers were especially upset by a belief that a deficiency-free survey by the state is an indicator of a survey that was not done correctly. There is a belief that a deficiency-free survey by the state often triggers a federal survey. Provider groups encourage the Federal Government to reward good nursing homes with less frequent surveys and to focus resources on poor performing facilities. Their presence in good homes causes a diversion of resources, taking time away from resident care. There was also support for an "outcomes-based survey" and a need to make "penalties consistent" by considering the amount of evidence when making decisions about deficiencies. Providers also identified inadequate reimbursement as a major cause of poor quality care. Higher reimbursement would eliminate a lot of quality problems, provider representatives contend. The potential reduction in Medicare funding could cause bankruptcy for many Missouri nursing homes. In addition, the CMS quality indicators, which will be posted on the Nursing Home Compare web site, were criticized for being "too complicated." Because these quality indicators use multivariate risk adjustment techniques, facilities cannot track their scores back to particular residents, thus making it difficult to use for quality improvement purposes. Lastly, state survey agency staff cited a need for improvements to the CMS Long Term Care Enforcement System, which tracks complaints, particularly for facilities with multiple complaints. Summary and ConclusionsThe Missouri program is unique for several reasons. First, it is the only quality improvement program identified by the research team that involves an agreement between a state survey agency and a university. The activities of the university are entirely separate from that of the state survey agency and each appears to respect the others' area of expertise. Surveyors defer to the QIPMO nurses on clinical issues and QIPMO nurses do not give advice regarding enforcement regulations. The future of the QIPMO program is uncertain, however, as support within the agency and the legislature is no longer sure. The QIO initiative at this particular time adds to the uncertainty by introducing a program that by some opinion duplicates what the state is paying the university to provide. Secondly, the program has a tireless proponent in Marilyn Rantz. She is a uniquely talented individual, highly trained and experienced in research protocols who brings enthusiasm, vision and commitment to the elderly, the long term care community and quality improvement efforts. The QIPMO program reports voluntary participation of 45 percent of facilities, despite the initial and unfortunate connection to the survey process. Facilities that use the program overwhelmingly praise the assistance and support offered by the QIPMO nurses. Lastly, the QIPMO program is unique in that it is research-based. The design of QIPMO was influenced by the results of a randomized clinical trial that was conducted in 1999. In this trial, facilities were assigned to one of three groups (facilities that received workshop and feedback reports only, facilities that also received clinical consultation and a control group.) This research indicated that on-going clinical consultation is effective in influencing change in nursing care that affects resident outcomes. This was the foundation for QIPMO and the "Show-Me" reports. Dr. Rantz and her colleagues have also studied the impact of QIPMO on CHSRA quality indicators in the state. In addition to analyzing median quality indicator scores, the research team analyzes trends for the 90th and 95th percentile, so that the effectives of the program in improving outcomes for low-quality facilities can be understood. ReferencesAHCA. State Summaries of Nursing Facilities, 2001/www.ahca.org/research/heynotes/statefactsheets-2001.pdf. Massoud, MRF. "Advances in Quality Improvement: Principles and Framework." QA Brief. Spring 2001. 9(1): 13-17 Missouri State Auditor. "Nursing Homes Medicaid Reimbursement Program." Report No. 2001-27. March 28, 2001. TexasOverview of the Texas Site VisitThis report describes our review of nursing home quality improvement programs that have been implemented in the State of Texas. We first present background information about the project team's site visit and the history and rationale for Texas's movement toward state-initiated quality improvement. This is followed by a description of each program reviewed by the project team. Findings regarding the strengths and weaknesses (as identified by those who participated in discussions) are presented, as is a discussion of the impact of the QIPs on quality of care and quality of life of nursing facility residents. Finally, lessons learned by the state are presented, along with a brief description of the perceived sustainability of the various QIPs. A Brief Description of Texas' Nursing Home IndustryTo put Texas in context with the other study states, we have included some comparative data from the American HealthCare Association's 2001 State Summaries of Nursing Facilities.7 As of Spring 2001, there were 1,251 nursing facilities in Texas, with 87,299 residents. Texas facilities are slightly smaller than those in the rest of the country, with an average of 102 beds per facility (vs. 108 nationwide). More of Texas' facilities are for-profit (81 percent vs. 65 percent nationwide) and more are part of a multi-facility chain (72 percent vs. 55 percent nationwide). Median nursing facility occupancy in Texas is substantially lower than in the country as a whole (73 percent vs. 87 percent). Direct care staff hours per resident, according to the OSCAR data reported by AHCA are somewhat lower than the national average (3.09 hours per resident day vs. 3.24 hours). 7. Source: www.ahca.org/research/keynotes/statefactsheets-2001.pdf. Overall Intent/Vision for Quality Improvement ProgramsAll but two of the programs described below (Liaison with Providers and Joint Training) are closely linked to each other and are managed by Dr. Cortes. The programs reflect his underlying vision of the meaning of "nursing home quality" and the need for mechanisms for quality improvement other than regulation/enforcement (e.g., via LTC survey or minimum staffing requirements) or the reimbursement system. Following the World Health Organization's definition, Dr. Cortes describes quality at the highest level as, "Doing the right thing in the right way at the right time for the right person in order to achieve the best possible outcome." A hallmark of the QIPs he supervises is the attention given to measurable, objective, evidence-based operational definitions of specific aspects of quality care. A good example of this is the way in which the program is dealing with the issue of restraint use. A review of federally-mandated nursing home data made it clear that Texas has for many years rated among the states with the highest rate of restraint use. To determine what constituted quality care with respect to restraint use, DHS commissioned a detailed review of the literature with the results reviewed by a technical panel. Based on this review, they determined that there were six situations where restraint use was clinically appropriate. Other uses were, by this definition,"inappropriate," even though they might not warrant a citation on the federal survey, which incorporates different, more subjective criteria. Thus, improving quality in this area translated into the specific goal of reducing the number of residents who are restrained for reasons other than the few determined to be clinically appropriate. The Texas Quality Monitor Program is designed in part to teach facilities this evidence-based best practice with regard to restraint use, to provide periodic detailed measurement in facilities regarding this best practice, and to provide technical assistance about general ways to reduce inappropriate restraint use. Another QIP, the legislatively-mandated "Statewide Quality Review" (discussed in more detail below), has been used to gather data relevant to this area such as the documented reasons for restraint use. In addition, this annual survey provides a means of tracking progress on changes in statewide quality with respect to selected issues, thus serving in part as a way to evaluate the effectiveness of the relevant QIPs. These programs work in tandem with educational efforts such as the Geriatric Symposium and QMWeb, also described below, that are used to further disseminate information about appropriate restraint use and other selected best practice areas. The general theory underlying the QIPs as a whole is that as consumers, practitioners, providers, and policy-makers are educated with respect to nursing home performance on specific, measurable, evidence-based aspects of quality, system quality will improve. In addition, there is a strong emphasis on focusing on a limited number of important issues (e.g., restraint use, hydration, psychotropic drug use) at one time. Finally, most of these QIPs have an associated evaluation component, reflecting a commitment to hold the programs up to systematic scrutiny. Description of State-Initiated Quality Improvement Programs in TexasThis section includes a description of Texas' quality improvement programs. The following programs were reviewed in detail with those interviewed:
The description of those programs is followed by brief mention of two additional programs:
Other EffortsAspects of Quality Improvement Programs that were Noted to Work WellWith regard to the Quality Monitor Program, virtually all of the Quality Monitors with whom we spoke were enthusiastic about the program and the opportunity to make a difference. Several noted that the program provided an opportunity to do the type of teaching they felt was needed. Mid-level program managers noted that program leadership had been exceptionally good and consumer advocates agreed with this assessment. Most of the providers and their representatives also expressed confidence in the current DHS leadership team, reported that opportunities for communication were good, and commented that the Quality Monitors with whom they had had contact were courteous and professional. But consumer representatives and providers we interviewed had difficulty pointing out any other particular aspect of the Quality Monitor Program as excellent at this stage. Since the program is still being rolled out, many were in a "wait and see mode." According to DHS, those providers who had taken the time to report their comments electronically to program managers as of August 2002 offered a generally positive picture of the Quality Monitor Program:
Those we spoke with who had positive comments about QMWeb noted the ease with it can be navigated, the usefulness of the content, and the cost/effectiveness of that approach to helping keep practitioners informed. The QMWeb was unfamiliar to many, however, and some who had tried it found using it to be somewhat daunting. With respect to the Quality Reporting System (QRS), consumer representatives and providers generally agreed about its strong points as well as some of the limitations (discussed below). The system was given high marks for being "consumer friendly" and easy to navigate. While those with whom we held discussions raised various levels of concern about the accuracy of the data and the validity of the rating system, virtually all said that in general, the rating system fairly accurately identified outliers (both excellent and poorer performers). Consumer representatives noted that they did suggest that potential consumers use the system as just one factor in making a decision about a nursing facility and stressed the importance of personal inspections and other sources of information. Providers noted that some facilities who scored well in the QRS were using the fact as a marketing tool. Two of the newer educational programs, the Geriatric Symposium and Joint Training, were widely acclaimed by those providers who had had experience with them. Aspects of Texas's Quality Improvement Programs Noted to be Less SuccessfulDuring our visit we heard several concerns from provider representatives, particularly regarding the Quality Monitor Program. Many of these less positive comments appear to have been influenced by differences of opinion regarding the type of technical assistance that DHS should be giving providers under the new program. Some had expected that the program would involve Quality Monitors providing more direct consultative assistance such as help with problems with a specific resident's care, or help more focused on how the facility might better meet survey requirements. Some also had expected the Quality Monitors to suggest the names of facilities that were doing some things particularly well. Instead, some expressed the feeling that the Quality Monitor Program appeared to be introducing new and even higher standards than the survey. Given the litigious climate in the state with respect to nursing home care and severe problems with liability insurance, providers were also particularly concerned that the Quality Monitor reports would be available to surveyors and ultimately discoverable in litigation. Most providers and association staff we spoke to were willing to give the program a chance, however, and thought that their most serious concerns might be addressed by toning down the language in the Quality Monitor's reports. Specifically, providers were quite concerned that the reports used phrases such as "inappropriate care," without making clear that this actually meant care not fully consistent with the particular best practices applied by the program. This problem was being addressed by DHS at the conclusion of our site visit. An additional theme regarding both the Quality Monitoring Program and the QMWeb centered on a perceived need for more clearly and simply presented information. Most with whom we spoke commented that there is too much information to sift through on the QMWeb and that DHS needed to have increased awareness of facility staff's lack of time for reading an abundance of background materials. Similarly, some stated that the information left by the Quality Monitor was overwhelming and had not been read. Regarding web-based dissemination of information, some noted that facilities in more remote locations may not have access to the internet and that not all facility staff were savvy about navigating the web. Few appeared to understand the relationship between the Quality Monitor Program and the evidence-based best practice models. As noted previously, however, the program had just recently been initiated at the time of the site visit and DHS program staff have subsequently developed new videos and other training materials to educate providers the program. Providers and consumer representatives raised some of the same issues with the Quality Reporting System as they did with the QMWeb. They were also concerned that the quality information suffered from a lack of timeliness, from frequent inaccuracies that take time to be corrected, and from a lack of risk adjustment in the quality indicators. Several providers were also concerned that deficiencies that have been appealed (and may be overturned) are still listed on the system. With respect to Joint Training, program staff noted that curriculum development had taken more time than originally expected, slowing program implementation, and that the program needed to be more fully coordinated with the quality improvement efforts under Dr. Cortes' direction. Impact of Texas's Quality Improvement Programs on Quality of Life/Quality of CareThere was a general consensus among those interviewed that it is to early to determine what impact, if any, the quality improvement activities undertaken in Texas will have on quality of care and quality of life in nursing homes. One consumer representative noted that in her view the new program was likely to have a marginal effect relative to the improvement in quality that might be realized were the state to mandate increased staffing. Some providers said that higher reimbursement rates would be a better lever to improve quality. The Ombudsman, by contrast, noted that the program was focusing on some areas that are very important to resident life and care and that changing practices in those areas would by definition positively affect quality. The question that naturally arises is the degree to which the program will be able to actually stimulate sustained changes in practices. Among the five facilities that had had a Quality Monitor visit and subsequently participated in discussions with the research staff, one cited an actual change in practice attributable in part to the Quality Monitor visit that reduced restraint use; one stated firmly that the program would have absolutely no effect; and the others fell somewhere in between, with more tending towards the less enthusiastic side. Quality Monitor staff with whom informal discussions were held at a half-day training program could each cite some instances where providers thanked them for assistance provided and appeared to have been inspired to implement some new practices. However, those same staff estimated that as many as four out of ten of the facilities visited in the early stages of the program were at best neutral, and sometimes hostile, regarding the new program. Those anecdotes present a picture of the range of possible responses to the new program. As noted above, a quantitative evaluation of actual changes in quality as defined in the program is planned as part of the next Statewide Quality Review. Sustainability and Lessons LearnedSince Texas, like most states, has substantial budget problems, virtually all programs are theoretically at greater risk now than in better economic times. Most of the programs are relatively inexpensive and during our visit, the only program that was said to be potentially vulnerable in the short term was the new Quality Monitor Program. Among those we spoke with, there was some discussion about the possibility of pressure being exerted on the legislature for repeal of the program, stimulated by one or more providers who are unhappy with the program's operation. Program staff and providers were asked what advice they might give to another state considering implementing programs similar to those in Texas. General lessons learned by program staff from their experience in implementing the Quality Monitoring Program included the following:
As noted above, providers had little experience with the program at the time of the site visit. A few we spoke to saw little benefit and advised other states not to implement a similar program. Others thought the program should be given a chance but thought a key lesson from the earliest days of the Texas program was the need for better information about the program's design and goals as well as greater collaboration between providers and DHS on key details. At the end of our site visit, one of the issues that most concerned providers--the wording of the Quality Monitor reports--was being addressed by program leadership. Role of the Federal Government in Quality ImprovementTime constraints limited exploration of this issue to a brief discussion with DHS staff involved in the new quality improvement projects. They offered the following comments and suggestions:
Summary and ConclusionsPolicy makers, practitioners, and advocates have long been concerned about quality issues in Texas nursing homes, with little agreement about the best way to address these. Over the last several years, the state has implemented a number of regulatory and other changes--including a major overall of the Medicaid reimbursement system--designed to address some key quality issues. Texas was one of the first states in the nation to implement (in 1999) a web-based quality reporting system. Some believe that these initiatives have focused on marginal issues and/or have involved the investment of too few resources to be effective. For example, a number of consumer groups believe that legislation requiring higher staffing would be the most effective action, while others believe that higher Medicaid reimbursement rates are essential. Some believe that the enforcement of quality regulations has been too lax, while others believe the opposite to be true. In 2000, the legislature mandated and funded an annual statewide assessment of nursing home quality issues. This annual empirical research effort provides Texas policy-makers with far better information about the scope of problems and progress towards goals than is available in other states. Research to date has revealed a somewhat higher level of customer satisfaction with care than some had expected but also confirmed serious issues in a number of areas such as restraint use. In 2001, the legislature again debated proposed approaches to address nursing home quality issues. While advocates of substantially higher payment rates and new staffing requirements were not successful, the legislature was responsive to a proposal, first suggested by providers, to try a different approach to harnessing state expertise to help providers improve quality. Some providers had long argued that surveyors focused solely on noting deficiencies, but did little to help homes actually understand what they might do to optimize quality. They proposed a program--initially modeled on one in Florida--in which state long term care experts in nursing, pharmacy, and nutrition would provide consultative technical assistance to homes, focusing first on those where the greatest problems appeared to exist. This initiative, called the "Quality Monitor Program," found support among some consumer advocates (at least initially) and key legislators long involved in nursing home reform efforts because it appeared to have the potential for providing additional state presence, focused on quality, in homes across the state. When the legislation passed, however, it was accompanied by a budget bill that funded the new program (and some smaller initiatives) by transferring 82 FTE from the survey, thus reducing resources available to regulatory enforcement by approximately 22 percent. For this reason, some consumer representatives and other stakeholders have come to view the new Quality Monitor Program's potential effect on quality with considerable skepticism, given the simultaneous reduction in resources available for regulatory enforcement. When the legislature mandated the new Quality Monitor Program, DHS program implementers had few sources of information to guide them in developing details of a program that met the legislative mandate and also might reasonably be expected to have a positive effect on quality. There have been no formal evaluations of the one long-standing state technical assistance program (i.e. that in Washington State); further, the Texas legislature mandated that the new Quality Monitors operate separate from the surveyors, in contrast to the Washington State program where those providing technical assistance also serve as surveyors. Given this situation, DHS staff focused on designing the new Quality Monitor Program to complement other state quality improvement efforts. In contrast to a number of other quality improvement initiatives that states have implemented over the years, the new Texas Quality Monitor Program has a clearly identified, objective, and measurable goal; a rational program logic model; and an evaluation plan. The program's success in terms of actually affecting quality depends on the degree to which sustained behavioral changes can be stimulated principally by educational efforts. In part this will depend on provider acceptance of the value of the types of changes the program envisions--namely greater conformity with selected, specific evidence-based best practices. At the time of our site visit, as the program was just getting started, program goals and the best practice protocols were not well understood by most of those we interviewed. In addition, knowledgeable staff at the provider organizations raised some issues about the degree to which local practitioners might fully embrace DHS' best practice concepts. Finally, most of the providers interviewed had expected a different sort of technical assistance than the Quality Monitors provide. Quality monitors are specifically trained not to instruct nursing facilities regarding specific solutions to specific problems with individual residents or issues; rather, they are to brainstorm with them, allowing facilities to "own" the system solutions. Recognizing the potential limitations of the program model (i.e., its dependence on education to effect sustained change), senior management was beginning to explore the idea of linking with the QIOs to provide more "hands-on" assistance for facilities. WashingtonOverview of the Washington Site VisitThis report describes our exploration of the nursing home quality improvement program initiated by the State of Washington. It begins with background information on the program and how the visit and discussions were structured and continues with a brief description of the origin and rationale for the program. A description of the program follows along with the research team's findings (from discussions with state employees, nursing facility respondents, and consumer representatives) regarding the overall strengths and weaknesses or the programs as well as a discussion of the effect that this program is said to have had on the quality of life and quality of care of Washington nursing home residents. It concludes with suggestions from program designers and participants to other states that might want to implement a similar program, the sustainability of the various programs and the respondents' opinions on the role of the Federal Government in quality improvement in nursing facilities. A Brief Description of Washington's Nursing Home IndustryIn order to put Washington in context with the other study states, we have included some comparative data from the American Health Care Association (AHCA) web site (AHCA, 2002). There are 275 facilities in Washington, with 21,195 residents reported as of September 2000. The average number of beds per facility is 94, which is slightly lower than the national average of 108. Washington's median occupancy rate per facility is 84 percent as compared to the national rate of 87 percent. The percentage of for-profit homes is close to the national average (69 percent vs. 65 percent), as is the proportion of beds that are dually certified for Medicare and Medicaid (45 percent in Washington and nationally). The number of direct care staff hours per resident is slightly higher than the national average (3.53 hours vs. 3.24 hours). Impetus for Washington's Quality Improvement ProgramWashington's QAN program has evolved over time. The state traces its origins to a program in the 1970s in which a "Nursing Care Consultant" from the state was in each facility about once a month to perform utilization review. Transformation of this role to include additional aspects of quality was spurred by Congressional passage of OBRA '87--the Nursing Home Reform Act. Implementing regulations for this law were delayed at the national level and Washington adopted the OBRA reforms in state law prior to full federal implementation. Washington adopted implementing regulations in 1989. In the 1980s there were totally separate functions for the QAN nurses and the Survey staff. State program officials with whom we spoke noted, "There was a yellow line down the center of the office to separate the two staffs." Conducting surveys was added to the role of the QAN staff in the early 1990s. QAN nurses, however, generally do not act as surveyors in the same facilities where they provide special quality assistance. Two factors contributed to the decision to merge these roles. First, a stakeholder's task force on quality had concluded that it was important for all to "be on the same page" with respect to understanding the regulations. Second, the state had fallen behind in its surveys and needed additional trained staff available to help. Today, QAN nurses have five functions: (1) providing "information transfer" (described below) for a set of assigned facilities; (2) conducting reviews of MDS accuracy (related to the state's casemix payment system) in those facilities; (3) conducting discharge reviews; (4) operating as surveyors both conducting regular surveys and occasionally serving as complaint investigators; and (5) serving as monitors of facilities that are in compliance trouble. Washington program officials with whom we spoke reported that in the early days of the QAN program federal officials frequently questioned the state about the appropriateness of the QAN program in the context of the survey, but that over time this concern had apparently lessened. Program officials noted the design of the QAN program has been influenced by a desire to "try to capitalize on federal funds." Thus, as the QAN nurses added surveys to their roles, the state was careful to keep the program in line with federal rules regarding appropriate roles for survey staff. For example, by state law the particular type of technical assistance provided by QAN nurses is called "information transfer." That term comes from federal procedures for the survey. According to a 1998 Report to Congress prepared by the Health Care Financing Administration (now CMS), "If some kind of activities [by survey staff] that could be construed as technical assistance are prohibited, it appears that other kinds of similar activities are permitted. Task IX in the [state Operations Manuel] Survey Procedures for Long Term Care Facilities states that: '…the state should provide information to the facility about care and regulatory topics that would be useful to the facility for understanding and applying the best practices in the care and treatment of long term care residents. This information exchange [italics added] is not a consultation with the facility, but is a means of disseminating information that may be of assistance to the facility in meeting long term care requirements. … Performance of the function is at the discretion of the state and can be performed at various times, including during the standard survey, during follow-up or complaint surveys, during other conferences or workshops or at another time mutually agreeable to the survey agency and the facility…'13 The Report to Congress goes on to say, "…[T]he State of Washington may resolve, or at least balance, the inherent conflict between the traditional surveyor role of determining compliance and an expanded information transfer role by separating these two functions. The two functions are not performed at the same time, and generally not performed by the same person.14
Overall Intent/Vision for Washington's Quality Improvement ProgramWashington State views the QAN program as one part of a three part integrated system of quality assurance: "an objective survey process, a responsive complaint investigation process, and a proactive [QAN] process. Through these activities, Washington monitors, measures, and intervenes to ensure compliance with defined state and federal requirements."15 Quality assurance is thus closely tied conceptually to compliance with regulations. The QAN program is intended to contribute to quality through four key mechanisms: providing "an early warning system," providing "multiple opportunities throughout the year to proactively identify issues with potential for harm," collecting "meaningful data for" use by other segments of the quality assurance process, and "translating regulatory expectations for facility staff."16 The state's vision of the nature of the QAN program's information exchange (technical assistance) is detailed in the program manual: "The QAN program is based on the concept that state agency staff members should set up a professional, supportive working relationship with nursing facility leaders and strive to keep the facility staff informed about potential compliance issues that are observed. Working closely with the facility Quality Assurance committee, resident's families and ombudsman, the QAN is effective in identifying potential problems and can provide technical assistance related to regulatory requirements and expectations. Correction of problems and achieving compliance is up to the discretion of facility staff. QAN staff do not consult on how to correct any issue. However, the frequent presence of QANs in the nursing facility helps to insure on-going, stable compliance with the intent of the regulations. This concept improves the survey process and is effective in preventing problems and ensuring on-going facility compliance to the ultimate benefit of the long-term care resident."17
Description of Quality Improvement Program in WashingtonIn Washington, quality assurance activities occur at several different levels. The state is divided into six geographic regions, with a core staff of surveyors assigned to each region. In each region, there are dedicated complaint nurses who investigate complaints initiated by the public or facility self-reports. Each region also has a team of quality assurance nurses, who make routine monitoring visits to the state's nursing facilities. The focus of our discussions was the state's QAN program, and this section provides a brief description of Washington's quality improvement program followed by a discussion of program funding and staffing. Aspects of Washington's Quality Improvement Program that Work WellThe QAN program is based on the concept that survey agency staff members can establish supportive, professional relationships with nursing facility leaders so that facility staff can be kept informed about potential compliance issues that are observed. Feedback from the Washington providers with whom we spoke suggests that the state has been effective in achieving this goal. Nearly all of those with whom we spoke were very positive about the work that QANs do as QANs (i.e., as opposed to their role as surveyors). Furthermore, virtually all of those with whom we spoke--state personnel, providers and consumer representatives--reported that one of the best things about the QAN program was its close ties to the Survey. Virtually all thought that the state's providing additional help to facilities regarding expected performance (i.e., as would be assessed in a survey) was important and helpful (although some thought that some other things might be more important to quality). Program features that contributed to this, including such things as the protocols and the information provided by QANs, were reported to be aspects of the program that work well. Positive features cited by providers included these comments:
The Ombudsmen with whom we spoke emphasized some similar positive features noting, "The emphasis is on best practices rather than failed practices [as with the survey]," "It has the potential to develop a working relationship with the facility so that they will call the QAN when the need help; when it works, what makes it work is the relationship." Both the Ombudsman and state program managers reported that it was important that the program is in every facility. One Ombudsman contrasted this program feature with the QIO model saying, "With the QIO, a facility has to volunteer for help. Our experience is that poorer facilities are very fearful of people from the outside. Thus with the QIO model, the rich get richer and the poor get poorer." Aspects of Washington's Quality Improvement Program Noted to be Less SuccessfulVirtually all with whom we spoke said that it would be better if the QANs had more time for QANing. As one provider put it "What's discouraging is that [the QAN program] seems to have been out of commission for a while; they must be doing surveys." Several providers with whom we spoke reported not having a QAN visit in over a year; one reported only one visit in 3 years. As noted above, most of the providers with whom we spoke also thought the program would be improved if the QAN nurses were not also surveyors. Of those holding this opinion, most said the problem was an inherent conflict of interest; a few thought the conflict of interest was not a problem, but that if the roles were separate, the QANs might have more time to be QANs. The QAN nurses with whom we spoke had very few suggestions about potential program improvements, other than more time for QANing per se. All said that the caseload was fine (setting aside the need to spend so much time on surveys) and that the QAN job provided a great deal of professional satisfaction. Suggestions for improvement involved things such as a desire for additional training (particularly on the computer) and mentoring. Some of the limited group of providers with whom we spoke had had some less than positive experiences with the program and these formed the basis of their comments regarding areas of the program that might be improved. Comments along these lines included the following:
The Ombudsmen with whom we spoke joined others interviewed in expressing concern that the QANs appeared to be being diverted to survey work. The Ombudsmen were particularly concerned because this was occurring at the same time that a change in the federal statement of work for survey agencies appeared to the Ombudsmen to give complaint investigation a lower priority than before. Thus, the Ombudsmen were concerned that the two early warning systems (complaint investigation and QANing) were both threatened at the same time. In addition, one Ombudsman with long experience in the field suggested, "The framework of the QAN program is the regulatory system. I'd like to reorient them to more innovation…they need a greater orientation towards quality of life." He further suggested that if a state were organizing a quality improvement program optimally, it should focus on empirically based, evidence-based practices. He reported that these exist in some areas that are also critical to resident quality of care and life (he saw these as inextricably intertwined) such as bathing, nutrition, and hydration. Impact of Washington's Quality Improvement Programs on Quality of Care/Quality of LifeNo formal evaluation of the effect of the QAN program has been made to date. Program managers noted that it is very difficult to tell what influences quality given the numerous factors involved. One manager reported, "In regions with more limited QAN presence we get more complaints." From that and other evidence she had concluded, "Yes, I know that [the QAN program] is positively affecting outcomes and quality." QAN nurses with whom we spoke were also generally quite positive about the effect of the program on quality. Most cited particular examples of positive changes related to the QAN program. For example, one nurse said, "Yes, I do believe it has an impact. I recently had a facility that had a bad reputation and lots of problems. Initially I was giving them [poor marks on the protocols]. Then we recently did a survey and it came out very well." But these nurses also noted the complexity of quality improvement. Several spoke about the difficulty and seeming futility of working with some facilities where, it was said, "The Administrator and Director of Nursing just can't get it together." In some cases the nurses said, the only thing that turns a facility around is when more and/or different staff are hired. The QAN nurses pointed out that the nursing shortage and current nursing training have a great deal to do with facility quality, regardless of the best efforts of the QAN program. Providers and ombudsmen with whom we held discussions similarly noted ways in which they thought the QAN program positively affected quality, but also stressed the importance of other factors such as resources. For example, one provider said, "It can definitely have a positive effect on quality of life. For example, some residents won't tell nursing facility staff things they will tell a QAN or another independent person coming in." Another said, "There is potential with the program to correct problems; a good QAN can help facilities prioritize quality problems and can help new Directors of Nursing and facility staff to improve quality." An Ombudsman echoed the theme of early correcting of problems noting, "I think [the QAN program] does have a positive effect because it is taking care of problems at an early stage." In general, most of those interviewed saw the clearest link between the QAN program and quality to be through the survey. That is, they viewed good performance on the survey as indicating better quality; to the extent that the QAN program helped facilities perform better on the survey--and many that we interviewed said that this happened--the QAN program could be said to positively affect quality. Sustainability and Lessons LearnedThe State of Washington currently has a $2 billion budget deficit; so all non-mandatory programs will be closely scrutinized. QAN program administrators, however, reported that the program has had the highest level of support by the Administration and that this has been true from the beginning--a critical factor in the program's success they say. One factor that may also help protect the QAN program from budget cuts is the numerous additional roles that the QAN staff plays in addition to QANing. Program managers said that they particularly emphasize the UR function and discharge review to the Legislature, as part of the Agency's mission to make sure that people in Washington State have appropriate choices for care. Further, QAN program managers purposely sought out the casemix review function (which they do as "contractors") because that was seen as a way to provide additional sustenance for the QAN program. By contrast, a newly implemented "Boarding Home/Assisted Living Quality Improvement Consultant (QIC) program that focused solely on quality consulting was recently stripped of its staff due to budget pressures. Nearly all those with whom we spoke would recommend the QAN program to another state, although many cautioned that any program would need to be tailored to specific conditions in the state. The very few dissenters took issue with the relative effectiveness of this type of program versus another, cautioning other states "Don't do a QAN program if your intent is to improve quality because the effect is likely to be negligible." The sharpest division among those interviewed regarded the issue of the dual role of the QAN nurses--as both surveyor and provider of information exchange (technical assistance). Program managers and QAN nurses all agreed that the two roles should be integrated, noting "We didn't truly understand the survey until we were trained on it" and "we started with the two roles separate but from experience put them together." Virtually all of the providers interviewed, however, said "The QANs should not also be surveyors," and "Keep the role pure." Despite that difference, many agreed that the regulatory focus of the QAN assistance (i.e., its close ties to the survey) was a good aspect of the program, one that might well be emulated by other states. Many from both the state and provider sides also emphasized the critical importance of hiring truly top people for the QAN job, given the nature of the task. The program manual and the protocols were also suggested as models for others. Role of Federal Government in Quality ImprovementWashington State was a pilot state for the recent federal piloting of national public reporting of quality indicators (QIs). Many of the suggestions for the federal role were related to the federal QI and quality measures (QM) initiatives and to the QIOs. There were very mixed opinions of the QI/QM public reporting, though general agreement among those who commented that "quality indicator" rather than "quality measure" was a more accurate descriptor, since those interviewed did not believe that the QMs are the only aspect of quality that should be considered when making judgments about facility quality. On QIOs, providers, state program managers, and the Ombudsmen were not very enthusiastic about Washington's experience to date, noting among other things that the QIOs appeared to know relatively little about NFs. Many (among those who were not state employees) said that the money might have been better spent in Washington by giving it directly to the state. Some also suggested that there should be direct grants to the states for innovative quality programs. Among other things, an Ombudsman suggested "[The Federal Government] should focus more funding on best practice programs; they should not divert money to the QIOs, but instead to QAN-like programs." Some providers expressed concerns about what they perceived to be over-regulation from the Federal Government; others were less concerned about the amount of oversight and most concerned about understandable regulations. One provider suggested that it would be very helpful if the Federal Government paid for a "pre survey," so that facilities would truly know what to expect. A number agreed with the provider who said, "We're over-regulated and under-funded." Those consumers who were interviewed at a meeting of the Washington Resident Councils Board were intensely focused on the importance of staffing to quality. They said "The best thing the feds can do is whatever it takes to improve staffing," "We need minimum staffing," and "More staffing is essential; sometimes I have to wait 1 hour and 45 minutes to get help." These consumers were also skeptical of the QI/QM initiative, saying "The QIs are too clinical," "The QIs don't tell the quality story; you need to talk to residents and the low level staff know what's going on," and "These was no correlation between performance on those QIs in the pilot and 'real quality' as we can see it from our perspective." Finally, these consumers argued that the Federal Government should do more to assure that there is more consumer (resident) representation on federal quality initiatives such as the QI/QM and QIO projects. Summary and ConclusionsWashington State was chosen for a site visit because it has a long-standing, statewide technical assistance program, called the "Quality Assurance Nurse" (QAN) program. The QAN program evolved from an earlier UR program. Today, QAN nurses have five functions: (1) providing "information transfer" (the official name for "technical assistance") for a set of assigned nursing facilities (caseload is 8-12 facilities/QAN); (2) conducting reviews of MDS accuracy (related to the state's casemix payment system) in those facilities; (3) operating as surveyors, both conducting regular surveys and occasionally serving as complaint investigators; (4) conducting discharge reviews to determine if resident rights are maintained when discharged/transferred; and (5) serving as monitors of facilities who are in compliance trouble. Program administrators and the experienced QANs we interviewed in a roundtable discussion at the Aging and Adult Services Administration's (AASA) central office were very upbeat about the program. These QANs said it was the best possible job because they could actually help facilities improve, while retaining the "stick" of possibly giving citations for deficiencies should that be needed. Program administrators and these QANs thought that "100 percent of facilities" were positive about the program; that the major complaint we would hear would be the diversion of QAN time to work on surveys. Providers and others (Ombudsmen, key staff at the 2 nursing home associations, and staff and members of the Board of the Resident Councils) did in fact repeatedly emphasize problems with the diversion of QAN time from "QANing" to other duties. As predicted, most said that their main issue with the program was that "QANs don't have enough time to be QANs." Additional issues, however, were also raised. Nearly all of the providers we interviewed (including those generally very positive about the program) said that the technical assistance functions and the survey functions were a conflict and advised other states not to adopt the "multiple hats" approach. All agreed that the success of the relationship between a facility and a QAN was very dependent on the particular situation…the skills of the QAN and a facility's own circumstances. Several of the providers we interviewed had had less than optimal experiences and believed that the program should be substantially changed to be far more objective (i.e., less discretion for the QAN nurse, more reliance on protocols); one firmly believed it should be discontinued. Both of the consumer groups with whom we held discussions were somewhat skeptical about the effect of the QAN program on quality and suggested alternatives. In the absence of a formal evaluation (including interviews with a scientifically representative sample of providers), it is difficult to know the actual effect of the program or the true extent of provider satisfaction/dissatisfaction. However, the fact that the program--in operation for over 20 years--has withstood the test of time is itself an indication of some success. Appendix B. Public ReportingWeb Links for Public Reporting SystemsThese states have developed and maintain data on nursing home quality that are available to the public. Florida's Nursing Home Guide Iowa's Health Facility Report Cards Maryland Nursing Home Performance Evaluation Guide Texas Long Term Care Quality Reporting System FloridaSample Facility Display1
Glossary of Terms Nursing Home Guide Watch List2Florida Nursing Home Guide Watch List is published by the state Agency is published by the state Agency for Health Care Administration to assist consumers in evaluating the quality of nursing home care in Florida. This Watch List reflects facilities that met the criteria for aconditional status, on any day, between July 01, 2002 and September 30, 2002. A conditional status indicates that a facility did not meet, or correct upon follow-up, minimum standards at the time of an annual or complaint inspection. Immediate action is taken if a facility poses a threat to resident health or safety. If the deficiencies that resulted in conditional status have been corrected, the current status as of August 1, 2002 is noted. Facilities appealing the state's inspection results are also noted. This document is subject to change as appeals are processed. Please refer to the Agency for Health Care Administration web site for the latest revisions: www.fdhc.state.fl.us or www.floridahealthstat.com. Based upon administrative proceedings or appeals, the following conditional licenses were rescinded and the facility was removed from a former Watch List:
Selecting a Nursing Home Selecting a nursing home is a very important decision. That's why the Agency for Health Care Administration encourages citizens to tour any nursing home being considered for a loved one, interview staff and talk with residents about the facility and refer to information listed in theFlorida Nursing Home Guide to aid in this decision making process. The Guide provides the following information about specific nursing homes: inspection history, ownership status, special services, charges or deficiencies and ratings. The Guide also suggests community-based alternatives to traditional nursing home care and questions to ask when choosing a facility. This Watch List reflects facilities that did not meet minimum standards, at any time, during July 1 to September 30, 2002. To request a copy of the annual Guide or the quarterly Watch Lists, call (888) 419-3456. These publications are also available on the AHCA web site at www.fdhc.state.fl.us or www.floridahealthstat.com. Licensure Status Nursing homes are licensed as standard or conditional. A standard license indicates the facility meets minimum standards and a conditionallicense indicates that the facility did not meet, or correct upon follow-up, minimum standards. Immediate action is required for deficiencies that pose a threat to resident health or safety. The Inspection Process The state Agency for Health Care Administration inspects nursing homes each year. The survey includes a facility tour; interviews with residents, families, staff, visitors and volunteers; assessments of resident rights, protections and activities; and medical record review. As necessary, the Agency also investigates consumer complaints against nursing homes. Nursing homes are required by law to post state inspection reports. Managed Care and Health Quality Area Offices
Explanation of Terms Deficiencies - Failure to meet established standards. Within 10 days of inspection, nursing homes are required to submit a written Plan of Correction detailing how the deficiencies will be corrected. State inspectors conduct follow-up visits to monitor the facility's progress. Given the complexity of the survey process, even the highest quality facilities may have some minor deficiencies. Severe deficiencies may result in fines, restriction of patient admissions, change of ownership, or closure. Class - Each deficiency cited is "classified" based upon as a Class I, II, III, or IV.
Scope - Deficiencies are given a scope by the agency according to the extent of the impact of the deficiency.
Under Appeal - Under Florida law, nursing homes have a right to challenge state inspection results. A conditional rating remains in effect until the appeal is settled or the deficiencies are corrected. The state Agency for Health Care Administration administers Florida's $10 billion Medicaid program; licenses and regulates nearly 19,000 health care facilities including 680 nursing homes, and 32 health maintenance organizations; addresses complaints for more than 550,000 health care practitioners statewide; and publishes health care data and statistics. Agency for Health Care Administration
IowaSample Facility Report CardFacility Report Care Search3Welcome to the Report Cards system provided by the State of Iowa Department of Inspections and Appeals, Division of Health Facilities. If this is your first time at this site please proceed to the About Report Cards page to gain a better understanding of the report cards system and how it relates to the process of surveying health facilities in Iowa. To navigate successfully through the Report Cards portion of the Health Facilties web site please use the tabs located at the top of each page. There are over 800 licensed and/or certified health care facilities in the State of Iowa. With the Report Card Health Facility Locator you can create a list of facilities to view Report Card information. To make the search for a particular facility easier you can search for a facility based upon the following criteria:
Please Note: If you encountering problems locating a facility through this search process or your computer locks up during a search please visit our Frequently Asked Questions page for tips on refining you search. Search Tips: When you enter information, you can enter partial names. For example entering "Iowa" in the Facility Name field would find all facilities with the word "Iowa" as any part of the name. Entering a county or city will limit the search to those areas. By default the list of facility types and counties will display all facility types for all counties in the state of Iowa which could cause your computer to lock up due to the amount of data being transferred to it. Please refine your search by selecting a facility type and/or county in Iowa. If you are unaware of the facility type of the facility that you wish to locate please review the list of facility types available on our Facility Types page. About Health Facilities Report Cards4These health facilities report cards are provided by the Iowa Department of Inspections and Appeals, Division of Health Facilities. The information is provided to assist you in reviewing or selecting health care facilities that can provide services for your family member(s). However, you should not rely solely on this information. These report cards cannot replace a personal visit to the facility. You should meet the staff who will work with your family members, tour the facility environment, and visit other residents and family before making your final decision. Visiting with others who have gone through this process can also help you in your own decision. For more information, see the federal guide on How to Choose a Nursing Home. In addition, the Medicare website also has a report card system tracking different information. If you have questions on how to save copies of the surveys contained within this web site please refer to our guide to downloading and saving information from this web site. To proceed to the Health Facility Report Cards Facility Search click here. For additional information you may want to contact the: Long-Term Care Ombudsman, Department of Elder Affairs 1-800-532-3213 Please Note: Visits completed before June 1, 1999 are not available on this web site. To obtain a copy of a visit completed before June 1, 1999 please call 515 281-7624 or send an e-mail to and including the e-mail include the name of the facility, date of visit (if known), your name, daytime phone number, and e-mail address. The Report Cards System uses Adobe Acrobat PDF (Portable Document Format) files to display individual facility information. To view Adobe PDF files you will need to download the Adobe Acrobat Reader. You will only need to download the Adobe Reader software once. It will then work every time you visit a website that contains PDF files. If you have questions about Adobe Acrobat click here. To download Adobe Acrobat Reader click here. Report Cards - Facility Detail5
Report Cards - Facility Visits6Visits to this facility since 6/1/99: 9
View the Scope/Severity Matrix for Substandard Quality of Care - The Scope/Severity indicator is found on the left-hand side of the State of Deficiency/Plan of Correction. (See Substandard Quality of Care for more information.) Disclaimer: All findings are subject to review and appeal. Reminder: All surveys and citations are Portable Document Format (PDF) files. To view surveys and citations, you must have Adobe Acrobat Reader installed.
MarylandSample Performance Evaluation GuideMaryland Nursing Home Performance Evaluation Guide7The Maryland Health Care Commission (MHCC), in consultation with the Department of Health and Mental Hygiene and the Department of Aging, produced this Guide on nursing homes with the assistance of experts in long-term care, representatives of the nursing home industry in Maryland, as well as nursing home advocates and long-term care ombudsmen. The Maryland General Assembly established the Commission to carry out several health care reforms in the State, including development of information on nursing home quality. The Commission is a public regulatory agency. This Guide is designed to assist consumers and their families in making decisions about selecting a nursing home. It includes:
Facility Characteristics8
* This column refers to the percentage of facilities in Maryland that have this characteristic. Resident Characteristics9
Quality Indicators10
The Quality Indicators (QIs) presented here have been developed for and are being used by the Centers for Medicare and Medicaid Services (CMS - formerly HCFA). The QIs are calculated using data from the Minimum Data Set (MDS). These data are collected on each resident and submitted to CMS by the indivdual nursing homes. Please note that the QI data presented in this Guide are abstracted from the quarterly and annual resident assessments. Assessments for newly admitted residents to a nursing home are not included in the calculations. The detailed operational definitions for these indicators used in this Guide can be viewed on the website of their developer. This site also has background information detailing the development of the indicators. http://www.chsra.wisc.edu/CHSRA/PIP_ORYX_LTC/QI_Matrix/main.htm QIs were developed to assist nursing homes with identifying areas for quality improvement or to monitor progress of improvement efforts. Nursing home inspectors use information derived from the QIs to target potential problem areas. In addition to the QI information, we recommend that prospective residents seek out other sources of information, such as speaking with family, friends, and healthcare providers, and also reviewing the facility characteristics, resident characteristics, and deficiency information presented in this Guide. You are also encouraged to visit nursing homes prior to making this important decision. We caution against judging a facility based on the QI scores alone, but are confident that the scores in conjunction with other information can help prospective residents to make informed decisions. ********************************************* CMS Nursing Home Quality Initiative The federal Centers for Medicare and Medicaid Services (CMS, formerly HCFA) has committed itself to an ongoing process of quality improvement in nursing homes. As part of this effort, CMS contracted with health care experts to identify a set of measures for further testing and analysis. From this, a new set of quality measures was developed. Several of these measures utilize a more concise risk-adjustment methodology to account for the severity of illness of nursing home residents. CMS is reporting the new measures publicly for nursing homes nationwide. These quality measures for each nursing home in Maryland are reported on the CMS website, Nursing Home Compare, showing the results for a particular nursing home compared to the state average and the national average. The Maryland Health Care Commission is presenting results of the Nursing Home Quality Initiative for individual nursing homes on this website in the same format used for the Quality Indicators that it currently displays. Each nursing home's score is compared to the range of scores for all other nursing homes in Maryland. To view the CMS Quality Measures on this website, click on the box below. Click here to go to CMS's Nursing Home Compare website to learn more about the Nursing Home Quality Initiative and how the measures are risk-adjusted: http://www.medicare.gov/nhcompare/home.asp Deficiency Report11The Office of Health Care Quality (OHCQ) in the Department of Health and Mental Hygiene (DHMH) conducts at least one annual inspection of every nursing home in Maryland. Inspections are conducted by nurses, dieticians, and sanitarians and take an average of three to five days to complete. Surveyors review all areas of a nursing home operation including nursing, medical care, food services, cleanliness, and resident rights. When a problem is found, surveyors determine the severity and scope of the violation. A score from A through L is assigned to each deficiency, with "A" affecting the least number of people and being the least severe and "L" affecting the most people and being the most severe. The nursing home is then notified and required to submit a Plan of Correction. If appropriate, follow-up inspections are conducted to make sure problems are corrected. The Guide includes deficiency information for all nursing homes in Maryland that have been inspected since January 1, 2002. If no deficiency or only minimal deficiencies (scores A, B, and C) have been found during the inspection, a facility is labeled as being in substantial compliance with the regulations. For all other deficiencies, their type as well as their scope and severity are listed. The nursing home's Plan of Correction is not included, but is available on request for a small fee from the OHCQ. If you are looking for a nursing home's inspection report that is not listed (i.e., the inspection occurred before January 1, 2002) or need additional help, please call OHCQ at 410-401-8201 or email to: . Listed below are the deficiencies that have been found by state surveyors in their most recent inspection. The information includes:
Further detail on the nature of the citations for any survey is available by clicking on the hyper linked "type of inspection" box entry. Allegany County Nursing & Rehabilitation Center
Listed below are any specific deficiencies cited during this inspection. In the absence of any citations, it was determined that the facility was in substantial compliance with regulations. Date of Inspection: 07/29/02
Date of Inspection: 06/11/01
For a complete summary of the deficiencies cited among all Maryland facilities, please click here.
TexasOverview of How Texas Quality Reporting System Evaluates Medicaid-Certified Facilities12Overview: Certified facilities are compared in QRS on the basis of four dimensions that depict some important aspects of quality. Quality has many dimensions. The quality of care provided to nursing home residents, the quality of life each resident experiences, the ability of a facility to meet all regulatory requirements, and customer satisfaction are all important aspects of quality. QRS uses four quality dimensions or axes to rate nursing facilities. Two axes reflect quality of care, and two more measure compliance with state and federal regulations. A brief background history of QRS development as well as answers to providers' frequently asked questions are available on the QRSProvider FAQ page. Interpret QRS ratings cautiously. QRS nursing home ratings are based on a reporting period that tends to indicate each facility's recent performance. QRS ratings do not indicate facility performance over the long term. Further, because QRS is only updated monthly, it is possible that very recent performance problems will not be reported. Even a facility that appears to have favorable QRS ratings may be under sanctions or penalties due to performance problems that occurred outside the QRS reporting period. The Regulatory Compliance History andEvents and Actions sections of each facility's quality profile contain additional historical information that can help you to better judge the consistency of facility performance over time. Use QRS information to help you make a nursing facility selection rather than as a short-cut to finding the best nursing home. You may also contact the DHS Consumer Information Hotline at 1-800-252-8016 or via e-mail to request additional consumer information about a particular facility. Comparisons: QRS uses comparison tables to show ratings for Medicaid-certified nursing facilities. These comparison tables include an overall rating score for each facility. Interpret this overall score with caution. The overall rating is the simple average of the four quality axis scores. It arbitrarily assigns equal importance to all the quality axes. As you read individual facility quality profiles, you will need to decide whether these axes are indeed equally important to you. Nursing facilities are listed in the comparison tables from highest overall rating to lowest. When several facilities earn the same overall rating, they appear in alphabetical order. Thus, if facilities South Village, West Oaks and Davis Retirement Center all have the same overall rating, they will appear in the comparison table in the order Davis Retirement Center, South Village and West Oaks. Quality of Care - the PAS and PDS Scales: QRS reports the quality of resident care using two ratings; these ratings serve as predictors of quality rather than as true measurements of quality. Both ratings are based on the Center for Health Systems Research and Analysis (CHSRA)Quality Indicators adopted by the Centers for Medicare and Medicaid Services(CMS, formerly HCFA) for use in monitoring nursing facility performance. The quality indicators are calculated from resident assessments that each facility submits to CMS. At this time, these assessments are not independently verified by either DHS or by CMS. Each resident is reassessed at least every 90 days. The quality indicator scores that QRS uses are based on assessments submitted during the first four months of the six month interval that precedes the date on which this Web site's database is updated (see the date at the bottom of each Web page.) The Potential Advantages Score (PAS) and Potential Disadvantages Score (PDS) are the ratings that summarize a facility's quality indicator scores. PDS: CMS uses the quality indicators to identify potential performance problems. That is, CMS advises nursing facilities to look for quality problems whenever an indicator condition is more common in that facility than in 90% of all other facilities. For three of the indicator conditions (Dehydration, Fecal Impaction, and Pressure Sores in Low Risk Residents), CMS recommends looking for quality problems on every occurrence. The PDS rates each facility based on the number of indicator conditions that suggest potential performance problems - each such condition is a potential disadvantage for residents in that facility. The most favorable PDS rating means that a facility has the fewest potential disadvantages. PAS: Where CMS currently uses quality indicators only to identify potential quality problems, QRS also uses them to identify potentially superior performance. QRS recognizes those facilities in which indicator conditions are less common than in 90% of all other facilities. The PAS rates each facility based on the number of indicator conditions that suggest potentially superior performance - each such condition is apotential advantage for residents in that facility. The most favorable PAS rating means that a facility has the most potential advantages. The Rating Scales topic below explains the relationship between the number of potential advantages and the PAS rating symbols as well as the relationship between the number of potential disadvantages and the PDS rating symbols. Because the purpose of the PAS and PDS ratings is to summarize and highlight the differences among resident groups from different facilities, DHS may periodically revise these relationships. When considering PAS, it is important to remember that it is based on quality indicator conditions that may be less common in a particular facility simply because the residents in that facility are more healthy or less prone to those conditions. Low quality indicator scores that create a favorable PAS do not always imply higher quality services. Similarly, PDS is based on quality indicator conditions that may be more common in a particular facility simply because the residents in that facility are less healthy or more prone to those conditions. High quality indicator scores that create an unfavorable PDS do not always imply lower quality services. Facility Surveys: Unlike PAS and PDS, the QRS Investigations and Survey scores are direct measurements of quality. The scores rate the facility's compliance with all applicable regulations and requirements. Investigations Score: DHS investigates all complaints that come to its attention concerning nursing homes. Substantiated complaint allegations that constitute a violation of state or federal regulations are usually cited by DHS as nursing home deficiencies. The Investigations Score is based on the nature, severity and scope of the deficiencies cited in each home during the preceding six months. Survey Score: A DHS survey team also inspects each nursing home at least once every 15 months (every 12 months on the average). The results of the most recent routine survey determine the Survey Score. This rating may not be a sensitive quality measure if the most recent survey occurred many months earlier; the quality of any service can change markedly over the course of a year. NOTE CAREFULLY: The number of deficiencies does not determine the compliance score; it is the nature, scope, and severity of the most severe deficiency that determines the score. A nursing home cited for a deficiency has a right to appeal the citation, and there are occasions on which such appeals lead to the reversal of even the most severe deficiencies. Therefore, both the Complaint and Survey ratings can appear to be poor only to suddenly improve as the result of such a reversal. In order to provide the most accurate ratings possible, all ratings are recalculated each month. Quality Profiles: QRS can show a quality profile that explains the facts behind the ratings assigned to a facility. This additional information may help you decide whether the facility is one that you want to consider further. The profile is a written report that includes the following:
Rating Scales: Each QRS rating scale consists of five rating symbols. A sixth symbol, NR, is used to show that the facility could not be rated for lack of information. The rating symbols range from - the most favorable rating to - the least favorable rating. Holding the mouse pointer over any rating symbol for a few seconds will show a brief description of a rating symbol on any QRS page. Most Web browsers will show the text explanation for any picture when this is done. The precise meaning of each symbol in each rating scale is given in the tables below. PAS is rated according to the following scale.
PDS is rated according to the following scale.
The complaint and survey scores are based on the following scale.
12. Source: http://facilityquality.dhs.state.tx.us/ltcqrs_public/nq1/jsp2/qrsHowQRS…, 4/1/2003. Appendix C. Technical Assistance ProgramsMaineFacility Feedback Report Laura Cote RN 1-1-10 Jane Doe - Mooselook Nsg Home - Anywhere, Me. Problems: Agitation - demanding - noncompliant to rules or restrictions - verbal abuse - manipulative - "push and shove" - "temper tantrums" - inappropriate sexual behavior - explosive outbursts Triggers:
When: Daily What Makes it Worse:
What Makes it Better:
Recommendations:
Thanks for the referral. Laura Cote, RN In-Service Outlines Laura Cote RN SERVICES AVAILABLE BEHAVIOR MANAGEMENT CONSULTATION For individual residents with specific behavior management issues, irregardless of their diagnosis. Consultation includes chart review, problem solving session with staff, brief meeting with the resident, written recommendations, and follow-up as needed. INSERVICE EDUCATION Provided to staff within their own facility. Seven inservices currently available:
Services are provided through the Bureau of Medical Services, Department of Human Services, and are available to any Long Term Care facility in the state of Maine at NO COST to the facility or the resident. The goal of these services is to assist staff in dealing more effectively with difficult behaviors by giving them a better understanding of the resident, why the behaviors are occurring, making recommendations, involving them in team problem solving where their input is valued, and providing them the education that will enable them to do their jobs more effectively and safely -- as well as improving quality of care and ultimately quality of life for the resident. Referrals can be made directly by calling 207-897-9573 INSERVICE OUTLINES Behavioral Approach Introduction: Relation to behaviors to approach
Helpful hints 1 hr. long and geared to all staff Documentation of Behaviors Painting word
pictures 1 hr. long and geared to licensed staff, med techs, social service, activities, and the MDS co-ordinator Alzheimer's - Practical Hints for Caregivers Brief overview of the disease
3 hrs. long, which is offered in one 3 hr. session or two 1½ hr. sessions - geared to all staff Intimidating Behaviors Definition of intimidation 1 hr. long and geared to all staff Problem Solving for Difficult Behaviors Define the problem behavior 1 hr. long and geared to all staff Behavior Profile Cards Basic identifying information 1 hr. long and geared to any staff who work directly with the residents targeted for the profile cards Elopement Risk factors 1 hr. long and geared to all staff MissouriSample ShowMe QI Report Facility Name .......: RANTZ ACRES Report for the Quarter Ending: December 31, 1999 ShowMe QI Report This Quality Indicator (QI) reflects the percent of residents with any injury* as recorded on their most recent MDS assessment. The graph displays several quarters of information for this QI. QI scores that fall below the lower threshold are thought to reflect good or excellent performance. QI scores that fall above the upper threshold may suggest a problem with resident care that needs further attention by your Quality Improvement Team. Focus on trends and examine the residents listed with the problem. The summary table below includes your facility's QI Score, statewide tenth percentile score, and percentile rank. * See attached Resident List for those residents with any injury indicated on their most recent MDS (M4 and J4) Prevalence of Any Injury Summary Table for Quality Indicator #1
Appendix D. Best PracticesFloridaSteering Committee's Consensus Document of Core Competencies for Dementia Training of Licensed Practical Nurses (LPNs) in Long-Term Care As one of the key professionals in LTC, the LPN performs important duties while serving as a mentor/role model for the CNAs and other staff providing direct care to persons with Alzheimer's disease and related disorders, which we designated in this document as dementia. Some less-common dementias may differ in their presentation and clinical course from Alzheimer's disease; we have emphasized as core competencies in dementia those pertaining to recognition and management of persons with advancing Alzheimer's disease. Under the supervision of the registered nurse, the supervising, teaching, and mentoring roles of the LPN, in concert with their central role in providing direct care to persons with dementia, prompted our initial focus on specifying the competencies for this pivotal position in the care continuum. Acknowledging that core competencies will change as knowledge and skills in dementia care advance, the following listing represents the current consensus of the Steering Committee's workgroup and leadership. Our proposed phases of training for LPN competencies is organized to reflect training that might occur in 1- and 3-hour sessions in compliance with the dementia training mandate of SB1202. Phase 1 (first hour of training)Competency 1.1 -- Understanding the characteristics of dementia and the special needs of the person with dementia Knowledge, skills, attitudes:
Competency 1.2 -- Adapts communication to cognitive/emotional needs of the person with dementia Knowledge, skills, attitudes:
Phase 2 (hours 2-4 of training)Competency 2.1 -- Demonstrates a working knowledge of dementia Knowledge, skills, attitudes:
Competency 2.2 -- Recognizes, prevents, and manages distress behaviors including agitation, pacing, exit-seeking, combativeness, withdrawal, and repetitive vocalizations Knowledge, skills, attitudes:
Competency 2.3 -- Understands special needs of family and friends of persons with dementia Knowledge, skills, attitudes:
Competency 2.4 -- Promotes independence in activities of daily living Knowledge, skills, attitudes:
Competency 2.5 -- Promotes an optimal environment that will support resident autonomy and enhance capabilities Knowledge, skills, attitudes:
Competency 2.6 -- Recognizes ethical issues that arise in dementia care and incorporates these into care approaches Knowledge, skills, attitudes:
Advanced Competencies (important, but not to be covered in the 1- and 3-hour initial dementia training sessions) In order to prevent excess disability, incorporates an approach to remaining capabilities and capitalizes on potential for rehabilitation
IowaPrinciples of Best Practices1 STRATEGY A best practices strategy should be developed, articulated, and incorporated into many of the services managed by organizations. Opportunities for collaboration should be used to help establish such program-level strategies. IDENTIFYING PRACTICES Focus on proven sources of best practices. Promote "leading edge" practices. Residents and their families are excellent resources. Also, use innovative methods to help identify new and emerging practices. SOURCES Examine practices in programs that have a reputation of excellence, especially those where resources have not been plentiful. Also, focus on Administrators or DONs recognized for special expertise to help identify best practices. METHODS Other suggestions for soliciting and identifying practices include having a competition among service functions, information exchange forums, mentors, speakers, soliciting electronic submissions, and old-fashioned bulletin boards. EVALUATING PRACTICES The concept is to establish criteria, up front, to benchmark and determine which practices are effective, or best, and have the greatest usefulness for residents and families. CRITERIA Use residents and families to help identify pertinent and consistent criteria, up front. Use criteria such as cost effectiveness, time savings, proven performance, satisfactions surveys and ease of implementation. Please send all Best Practices questions/comments to Best Practices Program Disclaimer Participation in the Best Practices Program is strictly voluntary on the part of Iowa long-term care facilities. The identification of a best practice at an Iowa long-term care facility is not an endorsement or recommendation of the practice by the Iowa Department of Inspections and Appeals or the Health Facilities Division. Nor does the identification of a best practice create a new standard used during the survey process. The identification of a best practice is solely designed to make available to other long-term care facilities in Iowa information about new or innovative methods positively impacting resident care and quality of life. Procedures of Best Practices2
Please send all Best Practices questions/comments to Best Practices Program Disclaimer Participation in the Best Practices Program is strictly voluntary on the part of Iowa long-term care facilities. The identification of a best practice at an Iowa long-term care facility is not an endorsement or recommendation of the practice by the Iowa Department of Inspections and Appeals or the Health Facilities Division. Nor does the identification of a best practice create a new standard used during the survey process. The identification of a best practice is solely designed to make available to other long-term care facilities in Iowa information about new or innovative methods positively impacting resident care and quality of life.
MarylandClinical Alert #1 -- Warfarin3 The Office of Health Care Quality has, in recent months, noted an increase in clinical problems related to the use of anticoagulants, especially Warfarin. Undesirable outcomes resulting from inappropriate prescribing, dispensing, administration and monitoring of these drugs are encountered frequently by our surveyors. A common theme in these cases is the systemic failure on the part of certain facilities to anticipate and address well-known complications associated with the use of these potent medications. The following case presentation highlights areas of concern: Resident #1 was a 78 year-old female with numerous diagnoses including hypertension, diabetes mellitus, osteoporosis and glaucoma. She was living at home independently until March 1, 2001 when she was admitted to the hospital with sudden onset of slurred speech and right-sided weakness. She was diagnosed with an embolic CVA and new onset atrial fibrillation. Treatment included the administration of IV Heparin, then Coumadin and active rehabilitation. She was transferred to a long-term care facility on March 6, 2001 for continued therapy. When admitted to the LTC facility she remained in atrial fibrillation. Coumadin was continued at a dose of 5 milligrams each evening. One day after admission, an INR was obtained and noted to be 1.44. The physician increased the dose of Coumadin to 7.5 milligrams each evening and ordered a repeat INR obtained in 2 weeks. The nursing staff administered the increased dose of Coumadin but failed to obtain the follow-up INR. As there were no standing orders or facility policy regarding the frequency of laboratory testing of residents on Coumadin, no further INRs were obtained. On April 12, 2001 (Day 35 in the nursing home), the attending physician examined the resident, noted limited progress in therapy but gave no new orders. On April 16, 2001 (Day 39) the consultant pharmacist reviewed this resident's care and recognized the lack of INR monitoring. However, the pharmacist simply left a written recommendation, in the medical record, for the physician to "consider monthly INRs while the resident is receiving Coumadin". As the facility had no system to promptly inform physicians of pharmacy recommendations, this information remained isolated in the medical record. On April 22, 2001 (Day 45) the resident complained of dysuria, which prompted the nursing staff to contact the attending physician. By phone, the physician ordered Bactrim to be administered twice daily for ten days. As of April 24, 2001 (Day 47) the resident's dysuria had resolved but gross hematuria had developed. The attending physician was again called and ordered the Bactrim discontinued and Cipro started for a presumed resistant urinary tract infection. The nursing staff despite the development of hematuria, continued to administer 7.5 milligrams of Coumadin nightly to this resident. On April 25 (Day 48), the resident complained of progressive weakness and "dizziness. The nursing staff told her that she needed to give the new antibiotic "time to work" and that she would eventually feel better. Later that day, in the absence of any trauma, bruising was observed on the resident's chest and left arm. The nursing staff failed to notify the physician of either the resident's complaints or the appearance of bruising. Coumadin was administered as ordered. Over the next 24 hours the resident remained in bed and became progressively more lethargic. Routine vital signs obtained by a nursing assistant on the morning of April 27, 2001 (Day 50) revealed a blood pressure of 84/48 and a pulse of 114 beats per minutes. The nursing assistant documented these results on the vital signs flow sheet, which was not seen by the nurse until later that afternoon. When the nurse went to evaluate the resident she was found to be obtunded, tachycardia, and hypotensive and found with diffuse bruising over her entire body. She was sent to the emergency room where her prothrombin time, the first one obtained in over six weeks, was found to be greater than 100 seconds. She was profoundly anemic with a hematocrit of 15.8%. A CAT scan revealed a large subdural hematoma and despite aggressive interventions the resident expired on hospital day number 2. The problems in the management of this case are many; some of the ones we noted include:
You can probably easily add to this list. Does someone in your facility know who is on anticoagulant medications? Does your facility have a policy to monitor residents on anti-coagulant therapy? When was your last in-service on anticoagulant therapy? For more information, please read:Warfarin Therapy: Evolving strategies in anticoagulation. American Family Physician, Feb 1, 1999. www.aafp.org/afp/990201ap/635.html Questions and/or comments regarding this clinical alert should be directed to: Joseph I. Berman MD William Vaughan R.N., B.S.N. Advance Healthcare Decisions4 "We have no simple problems or easy decisions after kindergarten." The right of a patient to accept or refuse medical intervention is a well-established principle in healthcare. In a setting that involves an alert, oriented and clearly competent individual, the process by which medical decisions are made is relatively straightforward. However, when disease or injury precludes the patient from actively participating in healthcare decisions, the situation becomes increasingly more complex. At these times, advance healthcare decisions are pivotal in preserving a patient's ability to direct his/her own care. Advance healthcare decisions generally involve choices made by competent individuals concerning their own desired end of life care if they should become terminally ill, have an end-stage condition, or be in a persistent vegetative state. The individual determines, while fully able, whether he/she wishes such interventions as the insertion or continued use of a feeding tube, the initial or continued use of a ventilator, the initiation or continuation of renal dialysis and/or the administration of antibiotics. While occasionally difficult for families and even those healthcare workers caring for patients to accept, these "advance directives" should be followed in the same manner that one would in the case of a competent and communicative patient speaking directly to them. The Office of Heath Care Quality frequently discovers situations in which healthcare providers do not honor the advance directives of patients in their care. The following deficiencies, which occurred in an area nursing home and hospital during 2001, are examples of such situations. COMAR 10.07.02.07 A (2)
COMAR 10.07.09.08 C (11)
COMAR 10.07.09.08 C (3)
Jane Doe was an 83 year old female when she was admitted to [a local nursing home] on February 26, 1998. Almost a year prior to her admission, while still living in the community, this resident wrote certain instructions related to her healthcare. These instructions were contained in a document entitled "Advance Health Care Directive for [resident's name]". The resident signed this document on March 19, 1997, and two individuals witnessed this signing. The creation of an advance directive is an important and proactive step in preserving one's autonomy as it relates to health care. An advance directive "speaks" for a resident at a time when she is unable, due to her medical condition, to communicate her wishes. End of life issues, such as withholding or removing life-sustaining interventions, are often the focus of advance directives. The Maryland statute governing advance directives, the Health Care Decisions Act, is found in the Code's Health General Article, §5-601 et seq. Mrs. Doe's advance directive instructed her healthcare providers to withhold or withdraw life-sustaining procedures if she met any one of the following criteria:
Mrs. Doe, in her advance directive, specifically addressed the issue of artificial nutrition as follows:
Mrs. Doe had been at [a local nursing home] for 18 months when on August 23 and September 20, 1999, two physicians certified that her medical condition was end-stage due to dementia. On July 17, 2000, two physicians again certified that her condition was end-stage secondary to dementia. At that time, the physicians also noted that tube feeding this resident, i.e. providing nutrition via a tube placed into the stomach, would be "medically ineffective". Mrs. Doe experienced a gradual decline in her overall condition and during the first several months of 2001, it became apparent that her oral intake of food and fluids was becoming inadequate. Her capacity to make medical decisions and her ability to communicate had become severely impaired, and she was no longer able to participate in decisions related to her healthcare due to her dementia. On April 5, 2001, she was admitted to (a local hospital) for the third time in the preceding six months due to dehydration. Despite Mrs. Doe's clear advance directives to the contrary, a feeding tube was surgically placed into her stomach during this hospitalization at the insistence of her son. Fluids and tube feeding formula were then administered to her at the hospital. She returned to [a local nursing home] on April 13, 2001. The clinical staff at the nursing center, including the attending physician, medical director, numerous members of the nursing staff, the administrator, the social worker and a corporate nurse who was a member of the facility's patient care advisory committee, all agreed that administering tube feeding to this resident would be against her wishes. Therefore, Mrs. Doe received only water and medications through the feeding tube. The facility's decision not to administer nutritional tube feeding per the resident's advance directive was communicated to the resident's family. On April 14, 2001, the attending physician visited the resident and wrote the following progress note: "... G tube [feeding tube] is placed against living will ..." The attending physician next visited Mrs. Doe on April 16, 2001, and wrote: "Pt [patient] had PEG [feeding tube] placed for nutritional purposes against the wishes of the patient. I personal [sic] do not recommend G tube [feeding tube] placement, I want to respect patient's wishes à continue G-tube [feeding tube] flushes [water only] no nutrition ..." Three days later, on April 19, 2001, the attending physician again came to the nursing facility and wrote: "Tried for family discussion with her son and daughter-in-law. Looks like they have contacted the attorney and made the decision if patient is not fed they will sue us ..." From the time Mrs. Doe was readmitted to the nursing facility on April 13, 2001, until the physician wrote her last note on April 19, 2001, all the resident had received was water and medications through her feeding tube. As she had on two previous occasions been declared in an endstage condition (due to dementia) and her own physician had deemed that providing nutrition via a feeding tube would be "medically ineffective", the decision to withhold nutrition was completely in accordance with her advance directive. However, after the resident's family made threats of legal action, the physician, on April 20, 2001, ordered the nursing staff to begin administering nutrition via Mrs. Doe's feeding tube. The nursing staff of the facility complied with this order and from April 20, 2001, through May 2, 2001, the resident was administered tube feeding formula daily. On May 2, 2001, the resident became acutely ill, was hospitalized, and did not return to the facility. In summary, it is clear that the staff at the nursing facility was not responsible for the placement of the feeding tube. That act, in direct contrast to the expressed wishes of the resident, was performed at the hospital. The staff at the nursing facility was, however, required to honor the instructions set forth by Mrs. Doe in her advance directive. Those instructions carried the same weight as if Mrs. Doe had spoken them herself during April and May of 2001. Despite clear misgivings on the part of the nursing and clinical staff, who were personally familiar with Mrs. Doe's wishes, the facility failed to allow this resident to exercise her right to refuse treatment, specifically the right to reject the artificial administration of sustenance. Instead of honoring the very clear and concise directives of Mrs. Doe, the facility inappropriately followed the wishes of the family, which were in absolute contradiction to the expressed wishes of the resident. Note: The nursing home appealed the above deficiency and sanction ($10,000.00 fine) to the Maryland Office of Administrative Hearings. A redacted version of the judge's decision in this case is available online at http://www.dhmh.state.md.us/ohcq/download/alj/pdf . The staff of OHCQ also conducted an investigation into the care Mrs. Doe received at the hospital where the feeding tube was inserted. The hospital was seemingly unaware that a feeding tube had been placed in this patient against her will. The Office of Health Care Quality wrote and forwarded the following deficiency to the hospital. A76 482.13(b)(3) Exercise of Rights The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with 489.100 of this part (Definition), 489.102 of this part (Requirements for providers), and 489.104 of this part (Effective dates). Based on a review of Jane Doe's medical record, the patient's advance directives and the hospital's policies and procedures, it was determined that the hospital failed to comply with the patient's advance directives that clearly indicated her desire to not be fed by artificial means. Jane Doe was an 83 year old female who had lived at a nursing home for about 4 years. She was diagnosed with advanced dementia, with severe brain atrophy. While still capable of making her own decisions, Jane Doe had executed an advance health care directive in March of 1997. Her son was appointed her health care agent and she also spelled out detailed health care instructions. Per the patient's instructions in her advance directives, which were to be acted upon when she was "incapable of making an informed decision," two physicians certified (July 17, 2000) that the patient had become "end-stage." The certifications specified that CPR (cardiopulmonary resuscitation) and G-tube feeding would not change patient's deteriorating health or prevent impending death. The patient's advance health care directive instructed "that no nutrition or sustenance be administered to me artificially, such as by the insertion of a feeding tube..." and upon finding that she has an end-stage condition "... that any such artificial administration be terminated immediately." Finally, she had directed, "... that such life-sustaining procedures be withheld or withdrawn, and that I be permitted to die naturally." The patient's son was appointed as health care agent but only to the extent the patient's wishes were unknown or unclear. On April 4, 2001, Jane Doe was found to be unresponsive at the nursing home and intravenous fluids were started. She was sent from the nursing home to this hospital for dehydration with related abnormal laboratory findings. At the time of admission to the hospital, the patient's medical record indicated that she underwent testing and observation to rule out a heart attack. "Aggressive intravenous hydration" was started to address her dehydration. The patient did not recover sufficiently to take food or liquids by mouth. The attending physician had stated in his admitting history and physical for Jane Doe, dated April 5, 2001, that "The patient is do not resuscitate with no ventilator or tube feedings. Orders are already in place." On April 7, 2001, the patient's attending physician wrote a progress note in the patient's chart saying, "Discussed with patient's son (who had medical power of attorney) and daughter-in-law about options. They have agreed to placement of a feeding tube. Reiterated patient is DNR/DNI (do not resuscitate/ do not intubate). Will insert NG-tube and start feeds today. Cardiac arrhythmias noted, am hesitant to treat in view of hypotension (low blood pressure); will monitor. Dr. _ _ called for GI (gastroenterology) consult." On April 9, 2001, the GI surgeon wrote his/her signature on the patient's informed consent, for placement of the G-tube. The son's name is printed, not signed, in the space for (Patient, Nearest Relative, Legal Guardian) signature. The surgeon's signature attests that the physician has explained to the son the surgical procedure, the alternatives, and possible complications and risks. On April 10, 2001, surgery to insert a feeding tube (G-tube) into Jane Doe's stomach was performed. Fluids and food were administered first through the NG-tube then through the G-tube for approximately a week, until her discharge on April 13, 2001, despite the patient's written directive that she should not be fed by artificial means. The attending physician stated in Jane Doe's hospital "Transfer Summary -- AMENDED REPORT" dated April 13, 2001, that "However, after discussion with the patient's daughter-in-law, she agreed to a placement at discharge of a feeding tube." The patient was discharged from this hospital to her previous nursing home placement, then to another acute care hospital and finally to a new nursing home placement. About one month after discharge from this hospital, the patient died with possible aspiration pneumonia, infections in her urinary tract, several decubitus ulcers and hypotension. The patient's attending physician and her daughter-in-law are the documented decision makers for the patient. The attending and the patient's daughter-in-law chose to institute treatments that would be medically ineffective as previously determined by the two physician certifications, i.e. treatment that would not alter the patient's deteriorating health status nor prevent her impending death. A review of hospital policies revealed that Hospital Policy Number RI10 was enacted in order to "foster respect for the inherent dignity of each person." This policy defines medically ineffective treatment and end-stage condition and allows a health care provider to withhold or withdraw life-sustaining procedures provided that the patient's attending and a second physician have certified the patient as having a terminal condition. The certifications (noted above) predated this hospital admission by nearly one year and certified that the patient's condition was "severe and permanent deterioration indicated by incompetence and complete physical dependency ... [and] treatment of the irreversible condition would be medically ineffective." Despite this fact, the G-tube was inserted. A review of Hospital Policy Number RI8 revealed that this hospital policy states to "Avoid conflicts of interest and/or the appearance of conflict." This policy stated that the hospital "assure that the care provided each patient is appropriate" and "ensure the integrity of clinical decision-making..." This policy states that it is in place to "promote employee and medical staff sensitivity to the full range of such needs and practices [physical, psychological, social and spiritual needs and cultural beliefs and practices]." There was no documentation to indicate that the physician, surgeon, anesthe-siologist or other healthcare providers or administrative staff voiced the conflict between the patient's advance directive and the insertion of a feeding tube by invoking the hospital's "specific mechanisms or procedures to resolve conflicting values and ethical dilemmas among patients, their families, medical staff, employees, the institution and the community" as identified in Policy RI8. A review of the hospital's Ethics Committee meeting minutes revealed that the hospital has a functioning system for the review of cases where there are conflicts regarding a patient's treatment, family wishes or advance directives. However, there was no documented evidence that the conflict between this family, the provider and the patient's advance directives had been referred to the hospital's Ethics Committee or for an ethics consult. Hospital staff interviewed on October 10, 2001, indicated that neither the physician nor the family referred this patient's case for an Ethics Consult. In response, the hospital revised its policies and implemented staff training to ensure that advance directives are followed. Discussion: Researchers Morrison and Sin compared the treatment of patients with acute illness and end-stage dementia to another group with acute illness and without end-stage dementia. They found that patients with end-stage dementia received as many burdensome procedures as cognitively intact patients and that only 7% had a documented decision made to forego a life-sustaining treatment other than cardiopulmonary resuscitation. In the case of patient #1, even though she had clearly indicated her desires through advance directives to forego life-sustaining treatment, she was unable to avoid the imposition of unwanted and medically ineffective therapy.
The Office of Health Care Quality considers the rights of patients to be paramount in any healthcare institution and will continue to monitor the response of facilities to this issue. For additional information, please read: Summary of Maryland Healthcare Decisions Act: http://www.oag.state.md.us/Healthpol/HCDA.pdf Morrison, R and Sin, A. "Survival in End-Stage Dementia Following Acute Illness." JAMA. 2000; 47-52. Administrative Law Judge's decision on the facility's appeal of this deficiency and civil money penalty:http://www.dhmh.state.md.us/ohcq/download/alj.pdf Questions or comments regarding this Clinical Alert should be directed to: Joseph I. Berman MD William Vaughan R.N., B.S.N. Wendy A. Kronmiller
TexasProblem-Oriented Best Practices5 February 2003 Spotlight on new resources Long Term Care is a multi-disciplinary endeavor with the care of the resident as its central focus. Because all disciplines must work coherently toward a common goal, each of the following topics addresses multiple aspects of LTC practice including resident evaluation, nursing care, facility administration and medical care. The Overview section in each topic includes findings from DHS Medical Quality Assurance (MQA) studies as well as a statement of performance expectations - a DHS MQA vision of high quality care. The accompanying bibliographies and resources are representative rather than exhaustive collections of current clinical thinking and research. Similarly, the regulatory tags that may be cited for deficient practices are representative rather than exhaustive. The accompanying Geriatric Symposium presentations represent the expert perspectives of the presenters rather than those of DHS. Where well-designed clinical trials permit defining evidence-based best practices, these have been used in the problem-oriented best practicesummaries. Where such evidence is lacking, expert consensus statements, clinical practice guidelines, case studies and regulatory requirements all offer some insight into what may constitute best practice. Every best practice framework in QMWeb is submitted to one or more clinical peer reviewers for comment. Where there are unresolved differences between MQA and a reviewer, these are noted in the Reviewers section of the page itself. Where opposing viewpoints each have some support in evidence and literature, the goal of QMWeb is to provide a balanced presentation. It is important to note that even when there is a sound basis for evidence-based best practice, the specific details of implementation (the more common and less strict meaning of best practice) may vary from one venue to the next simply because resident needs, staff expertise and other resources vary from one venue to the next. Therefore, the following pages serve best as frameworks or toolkits from which to design facility-specific care systems rather than as simple cookbook recipes for deficiency-free (let alone, optimal) care. This section of QMWeb is a work in progress. Only the topics in bold represent completed frameworks. The remaining pages are either preliminary frameworks that have not yet undergone peer review or simply resource pages whose corresponding best practice frameworks remain to be completed. Expect the number of completed best practice frameworks to grow steadily over the next two years in response to provider needs identified through the Quality Monitoring Program, the Statewide Quality Review Process, and the DHS Geriatrics Symposium Series. Ethical Issues
Geriatric Syndromes
Organizational & Administrative Practices
Prescribing Practices
Prevention Practices
Last updated: May 6, 2003 Restraint Reduction6 OverviewThe DHS Medical Quality Assurance vision for restraint reduction in Texas LTC is Resident-centered evaluation and care planning for restraint-free environments. Definitions and Scope In this framework, the term restraints focuses exclusively on devices applied to a resident's wrists, trunk or waist that limit the resident's normal access to the environment or self and that the resident cannot remove at will without assistance. While the use of other devices that achieve these same ends is also discouraged, the findings described below apply only to these three general classes of devices. According to MDS Quality Indicator statistics, Texas has ranked among the four states with the highest prevalence of restraint use during 2000-2002.[1] An independent assessment of 1972 Texas nursing facility residents conducted for DHS by the Texas Nurses Foundation during FY2002 showed that 19.5% (n=385) of the residents had spent some time in restraints during the preceding 7 days.[2] The majority of these residents, 368/385 (95.6%), had spent time in restraints each and every day during the last 7 days. Among restrained residents, fewer than 10% (n=34) had a clinical problem that an expert panel deemed unlikely to be properly addressed without the use of restraints. Based on structured assessment, the prevalence of necessary restraints was 2.3% rather than the observed 19.5%. This is consistent with the results of restraint reduction trials that show restraint prevalence can be decreased to 5% or less.[9, 16, 17] In the Texas cohort, no resident appeared to be in restraints for punishment or for facility convenience. Rather, the majority was in restraints because caregivers believed that they were appropriately addressing a resident safety issue. The following proportions describe the 351 residents who were restrained without a compelling clinical indication:
Thus, the dominant reasons for using restraints in Texas nursing homes appear to be concern for two common geriatric syndromes - falling and wandering.[2] In the Texas cohort, more severe resident ADL and cognitive impairment are associated with the application of restraints. These findings are consistent with findings of multiple research studies [3, 4, 5, 6] It also appears that families, concerned for resident safety and not knowing what best to do, ask for the use of restraints in a significant number of instances where they are inappropriate. Considerations for Avoiding and Reducing Restraint Use Beyond the ethical issues of resident's rights (the principles of individual dignity and self-determination) and quality of life issues, there are compelling clinical reasons to use the least restrictive intervention to deal with the problems that are commonly given as reasons for using restraints. The first clinical reason is to preserve resident function - to prevent loss of independence and ADL capacity and thus avert greater care-giving burden. The restraint reduction literature identifies the adverse effects of restraint use including the following:[19, 24]
The second clinical reason is to ensure resident safety. Although commonly viewed as an intervention to promote resident safety, restraints actually compromise safety. The complications of restraints can be serious and include injuries and death.[7, 8] Common reasons for restraints include assisting resident posture, keeping residents from dislodging feeding tubes or other medical devices, limiting resident access to wounds, preventing scratching injuries, and preventing inappropriate disrobing among others. All of these hypothetical scenarios can be managed with less restrictive interventions. Cushions, bolsters and other physical therapy devices can be used to support posture. Various binders and dressings can be used to limit resident access to tubes, devices and wounds. Proper nail care can minimize or eliminate scratching injuries. And, special clothing adaptations can make disrobing very difficult without resorting to restraints. However, every one of these interventions requires individualized care planning, and no one intervention will meet the needs of every resident that has a particular problem. That is, restraint reduction often requires an individualized, resident-centered approach rather than a generic, problem-centered approach.[9, 10] Myths and Misconceptions MYTH: Restraints Protect Residents from Falls and Injuries. Some restraint reduction studies show an increase in falls but to levels no greater than seen in control groups; other studies show that with appropriate care planning this increase is minimal to negligible.[11, 12, 13, 14] All of the studies show no increase in serious injuries as a result of restraint reduction; and, other studies show an increase in serious injuries when restraints are used.[7, 8] MYTH: Restraints Decrease Staff Time. Restraint reduction research shows that there is no increase in the staff time needed to meet the needs of residents in whom restraint use is discontinued.[13, 15] MYTH: Restraint Use Decreases Cost of Care. Restraint reduction research shows that there is little or no increase in costs required to meet the needs of residents in whom restraint use is discontinued. The increased cost attributable to special devices needed to accomplish restraint removal has been measured at 3 cents per day per resident released from restraints, and this is comparable to the cost of restraint devices themselves.[14, 17] MYTH: Restraint Reduction Requires Increased Psychoactive Medication Use. Research shows that this belief is common and erroneous.[13,16] MYTH: Restraint Use Decreases Facility Liability. There is no evidence that facility liability cases have ever been lost solely on the basis that the facility had failed to apply restraints.[17, 18] There is no literature that shows that the application of restraints constitutes best practice for managing fall risk or wandering. In fact, the lost liability cases due to injuries related to restraint use serve as a reservoir of evidence against the argument that restraints constitute best practice. The Texas Department of Insurance recognizes restraint use as a key facility liability risk-management issue because of liability claims arising from the use of restraints. Resident EvaluationThe minimum evaluation prior to using restraints consists of the following: Clear Identification and Understanding of the Clinical Problems, Goals and Risks Why are restraints being considered? What are the clinical problems that restraints are supposed to address? Is there an evidence basis that supports restraints as best practice in addressing these problems? What clinical outcome or end-point is desired? Are the potential untoward outcomes associated with restraint use acceptable to the resident and family? Some successful restraint reduction programs use a formal physician's order form that includes these and other elements such as informed consent.[16] Trial and Evaluation of Less Restrictive Alternatives With the possible exception of the circumstances described in the DHS structured assessment for restraint use, every other clinical problem can and probably should be addressed with less restrictive interventions. To proceed directly from problem identification to the use of restraints without a trial of individualized and less restrictive alternatives does not constitute best clinical practice. Yet, in 28.5% of the cases of inappropriate restraint use in the Texas cohort, there was no evidence that less restrictive alternatives had been tried.[2] Since this figure was based on record reviews requiring minimal documentation that alternatives were tried, the 28.5% rate is a conservative. Structured Resident Assessment and Care Planning DHS recognizes that there are occasional clinical situations in which the use of restraints may simply be unavoidable because there is no alternative that has an acceptable risk-to-benefit ratio for the resident or others. These rare circumstances include the following:
While there may be other circumstances that are compelling reasons for restraint use in nursing facilities; they are expected to be variations of these four indications, and they appear to be rare. The DHS Quality Monitoring Program uses this structured resident assessment to evaluate the appropriateness of resident assessment, care planning and care for residents who are restrained. Practical Guide to Quality ImprovementKey Components of Successful Restraint Reductions Programs Successful restraint reduction initiatives require changes in facility policy, staff and family attitudes, beliefs and care practices.[25] The following structural and process elements contribute to success:[9, 10, 13, 14, 19, 20, 21, 22, 23]
Part I. Prepare to Succeed (education)
Part II. Implement Restraint Reduction - Eliminate Inappropriate Restraints (routine process) Appropriate care planning for restraint reduction is only the beginning of the elimination of inappropriate restraints.
Part III. Implement Restraint Prevention - Eliminate the Initiation of Inappropriate Restraints (event-driven process)
Related TechnologiesThere are a variety of technologies related to restraint reduction. These technologies afford solutions to the clinical problems that lead to restraint use - falls, wandering, self-removal of medical devices, among others. These include various types of alarms, beds, devices to assist ambulation, positioning devices, wheelchair modifications, special clothing, dressings and environmental modifications. The presentations and resources sections in this framework provide examples of such technologies. Related Licensure and Certification TagsThe following deficiencies may be cited for the inappropriate use of restraints. Tags that might be cited as evidence that restraints were used inappropriately are also listed. The deficiency list is representative rather than exhaustive.
Related DHS PresentationsAll presentations on the Quality Matters web can only be viewed with Microsoft Internet Explorer 5.0 or later. No other browser is currently supported. However, you can follow this link to obtain the same presentations on CDROM for offline use with other browsers. Note that optimal viewing requires broadband internet access such as DSL line or cable modem. Although slow modem connections (down to 28.8 KB) are also supported, download times are much longer and the audio quality is phone-like rather than CD-quality.
Additional Resources (including online resources)Online A Values-Based Approach to Restraint Reduction (Journal for Healthcare Quality, 2001) Colorado Foundation for Medical Care (Resident Assessment Guide and Tools) HCFA Restraint Reduction Newsletters Untie the Elderly (Restraint Reduction Training Program) A Restraint Reduction Letter to Families (This sample was graciously provided by Mr. Kinny Pack of Azle Manor. This is not a mandated form; it is simply a resource.) In Print Toward a Restraint-Free Environment Book. Edited by Judith V. Braun, Ph.D., Associate Administrator of the Hebrew Home of Greater Washington, Rockville, Maryland, and Steven Lipson, M.D., M.P.H., Medical Director of the Hebrew Home of Greater Washington and Associate Professor at the Georgetown University School of Medicine, Washington, DC. Bibliography[1] Centers for Medicare and Medicaid Services; MDS Quality Indicator Report. (2000-2001). online. [2] Cortes, L. Restraint Use in Texas Nursing Facilities - Preliminary Findings of the 2002 Statewide Review of Quality of Care in Texas Nursing Facilities. [3] Burton,LC., German, PS., Rovner, BW., Brant, L; & Clark, R. Mental illness and the use of restraints in nursing homes. The Gerontologists 1992;32(2):164-70. [4] Karlsson S, Bucht G, Eriksson S et al. Physical restraint in geriatric care in Sweden: Prevalence and patient characteristics. Journal of American Geriatrics Society 1996;4411:1348-54. [5] Phillips CD, Hawes C, Mor V et al. Facility and area variation affecting the use of physical restraints in nursing homes. Medical Care 1996;3411:1149-62. [6] Karlsson S, Bucht G, Eriksson S et al. Factors related to the use of physical restraints in geriatric care settings. Journal of American Geriatric Society 2001;49:1722-8. [7] Miles S, Irvine P. Deaths caused by physical restraints. The Gerontologist 1992;32(6):762-6. [8] Tinetti M, LieW, and Ginter S. Mechanical restraint use and fall related injuries among patients of skilled nursing facilities. Annals of Internal Medicine 1992;16:369-74. [9] Cohen C, Neufeld R, Dunbar J, et al. Old problem, different approach: alternatives to physical restraints. Journal of Gerontological Nursing 1996;22(2):23-9. [10] Werner P, Koroknay V, Braun J et al. Individualized care alternatives used in the process of removing physical restraints in the nursing home. Journal of American Geriatrics Society 1994;42:321-5. [11] Ejaz FK, Jones JA, Rose MS. Falls among nursing home residents: An examination of incident reports before and after restraint reduction programs. Journal of American Geriatrics Society 1994;42:960-4. [12] Capezuti E, Evans L, Strumpf N et al. Physical restraint use and falls in nursing home residents. Journal of the American Geriatric Society, 1996; 44:627-33. [13] Evans LK, Stumpf NE, Allen-Taylor SL et al. A clinical trial to reduce restraints in nursing homes. Journal of the American Geriatric Society 1997;45:675-81. [14] Stratmann D, Vinson MH, Magee R, Hardin SB. The effects of research on clinical practice: The use of restraints. Applied Nursing Research 1997;10(1):39-43. [15] Phillips CD, Hawes C, Fries BE. Reducing the use of physical restraints in nursing homes: Will it increase the costs? American Journal of Public Health 1993;83(3):342-8. [16] Levine, JM, Marcello, V, Totolos, E. Progress Toward a Restraint-Free Environment in a Large Academic Nursing Facility. Journal of the American Geriatric Society 1995, 43(8):914-8. [17] Dunbar JM et al. Taking charge: The role of nursing administrators in removing restraints. Journal of Nursing Administration 1997;27(3):42-8. [18] Kapp MB. Restraint reduction and legal risk management. Journal of the American Geriatric Society 1999, 47(3):375-6 [19] Terpstra T, Terpstra T,L., Elaine VD., Reducing restraints: Where to start. The Journal of Continuing Education in Nursing 1998;29(1):10-16. [20] Stilwell, EM. Nurses' education related to the use of restraints. Journal of Gerontological Nursing 1991;17(2):23-6. [21] Neary, MA et. al. Restraints as Nurse's Aides See Them: What do the people who most often apply restraints know about the alternatives? Geriatric Nursing 1991;12(4):191-2 [22] Strumpf NE, Evans LK, Wagner J et al. Reducing physical restraints: Developing an education program. Journal of Gerontological Nursing 1992;18:21-7. [23] Bradley L, Siddique CM, Dufton B. Reducing the use of physical restraints in long-term care facilities. Journal of Gerontological Nursing 1995;21(9):21-34. [24] Morse, JM, McHutchion, E. Releasing Restraints: Providing Safe Care for the Elderly. Research in Nursing & Health 1991, 14:187-96. [25] Janelli LM, Kanski, GW, Neary MA. Physical restraints: Has OBRA made a difference? Journal of Gerontological Nursing 1994;20:17-21. Literature Review Evidence Table Table of Additional References ReviewersPeer Reviewer: David A. Smith, MD, CMD Dr. Smith practices Long Term Care Geriatrics in his private practice in Brownwood, Texas. He is a Professor in Family Medicine at the Texas A&M School of Medicine and is also currently President of the Texas Medical Director's Association. Your FeedbackYou may use this link to submit an anonymous evaluation of this page. DHS Medical Quality Assurance is interested in your comments regarding this page, whether you found it helpful, and your suggestions as to how we can make the QM Web more responsive to your needs as a provider of Long Term Care services. While we will use your ideas to improve the content of this site, please be aware that because this feedback is anonymous, MQA will not be able to respond to questions. Any question that requires a reply should be sent using this QM Webmaster link. Last updated: September 19, 2002
Appendix E. Provider Training ProgramsFloridaFlorida's Teaching Nursing Home Program1 Florida's Teaching Nursing Home (TNH) Program was created in 1999 via legislative House Bill 1971 and was funded in 2000 to establish an integrated long term care (LTC) training curriculum for physicians and initiate an online geriatrics university. The TNH program is under the direction of Bernard Roos, MD, Director of the Stein Gerontological Institute at the Miami Jewish Home & Hospital for the Aged. The TNH program is committed to integrated systems and to linking LTC resources and other community-based healthcare assets with professional and academic talents throughout our state. The TNH program has already established productive working relationships with several major nursing homes, with each of Florida's medical schools, and with several nursing schools. Mission: Forging a more integrated and patient-centered LTC system through a comprehensive multidisciplinary statewide program of excellence in geriatrics training and research related to best practices and standards of care. Goals:
Strategy: Provide forums, initiative, and core resources for identification and prioritization of LTC issues promote research and training in relevant best LTC practices and their adoption by communities and their entire range of health-care providers.
1. Source: http://www.gate.net/~sgi/page%205.htm, 5/12/2003. MissouriEducational Materials2 Below are several educational materials developed by the MU MDS and Quality Research Team, the Statewide Planning Committee for Improving MDS Assessment and Use, and the Quality Improvement Program for Missouri. All of these documents are in Adobe Portable Document Format (PDF), therefore you will need Adobe Acrobat Reader to view and print the documents. You can download the free Adobe Acrobat Reader at http://get.adobe.com/reader/. We hope you put these materials to good use. The Resident Assessment Instrument
Quality Indicator (QI) Reports
Other Educational Tools
Copyright (c) 2003 2. Source: http://www.nursinghomehelp.org/edmat.html, 4/1/2003. TexasConference Calendar3 Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec Organizations that sponsor LTC educational events and that wish to have their scheduled conferences listed in this calendar should send an email to the QM Webmaster. Please include the title of your conference, a link to your conference web page if you have one, the name of the sponsoring organization, and the date and the location of the conference. A separate calendar of DHS Joint Training events for providers and surveyors is available on the LTC-R Web. January 2003
February 2003
March 2003
April 2003
May 2003
June 2003
July 2003
August 2003
September 2003
October 2003
November 2003
December 2003
Last updated: January 27, 2003 3. Source: http://mqa.dhs.state.tx.us/QMWeb/calendar.htm, 4/23/2003. Appendix F. Facility Recognition ProgramsFloridaApplication for Nursing Home Gold Seal1 Refer to sections 400.235, Florida Statutes and 59A-4.200, Florida Administrative Code for regulations. Attach additional pages as necessary to respond to information requested.
A. Nursing Home InformationPlease complete this section for the nursing home being recommended for the Gold Seal Award.
Facility Contact Person for Gold Seal Information
B. Recommending Person or Organization
C. Regulatory HistoryThe information provided and the quality of care requirements in rule will be verified by the Agency for Health Care Administration prior to proceeding with application review. 1. Section 400.235(7), Florida Statutes -- A facility must be licensed and operating for 30 months before it is eligible to apply for the Gold Seal Program. The agency shall establish by rule the frequency of review for designation as a Gold Seal Program facility and under what circumstances a facility may be denied the privilege of using this designation. The designation of a facility as a Gold Seal Program facility is not transferable to another license, except when an existing facility is being relicensed in the name of an entity related to the current licenseholder by common ownership or control, and there will be no change in the management, operation, or programs at the facility as a result of the relicensure. a. Has the facility been licensed and operating for the past 30 months? Yes No b. Date the current licensee became licensed to operate this facility: _________________________ 2. Section 400.235(5)(a), Florida Statutes -- Facilities must have no class I or class II deficiencies within the 30 months preceding application for the program. a. Has the applicant facility been cited for any Class I or Class II deficiencies within the 30 months preceding this application? Yes No b. If yes, please describe why the facility should be eligible for the Gold Seal Award: _____________________________________________________________________ 3. Section 400.235(5), Florida Statutes -- A facility assigned a conditional licensure status may not qualify for consideration for the Gold Seal Program until after it has operated for 30 months with no class I or class II deficiencies and has completed a regularly scheduled relicensure survey. a. Has the facility been issued a Conditional license in the preceding 30 months? Yes No b. If yes, please describe why the facility should be eligible for the Gold Seal Award: _____________________________________________________________________ D. Financial Soundness and Stability -- Section 400.235(5)(b), Florida Statutes and 59A-4.203, Florida Administrative CodeAttach evidence of financial soundness and stability in accordance with the protocol contained in agency rule 59A-4.203. E. Consumer Satisfaction -- Section 400.235(5)(c), Florida StatutesFacility must participate consistently in the required consumer satisfaction process as prescribed by the agency, and demonstrate that information is elicited from residents, family members, and guardians about satisfaction with the nursing facility, its environment, the services and care provided, the staff's skills and interactions with residents, attention to resident's needs, and the facility's efforts to act on information gathered from the consumer satisfaction measures. a. Describe the approach to assessing consumer satisfaction in the facility. _____________________________________________________________________ b. Once AHCA has initiated a consumer satisfaction survey in the facility, describe the facility's participation in the AHCA survey process, refer to section 400.0225, F.S. and applicable rules. _____________________________________________________________________ F. Community / Family Involvement -- Section 400.235(5)(d), Florida StatutesPresent evidence of the regular involvement of families and members of the community in the facility. _____________________________________________________________________ G. Stable Workforce -- Section 400.235(5)(e), Florida Statutes and 59A-4.204, Florida Administrative CodeFacility must have a stable workforce, as evidence by a relatively low rate of turnover among certified nursing assistants and registered nurses within the 30 months preceding application for the Gold Seal Program, and demonstrate a continuing effort to maintain a stable workforce and to reduce turnover of licensed nurses and certified nursing assistants. Include the following staff for information requested in this section: certified nursing assistants, licensed nurses (registered nurses and licensed practical nurses), director of nursing and administrator. Present evidence of meeting at least one of the following to demonstrate a stable workforce: have a turnover rate no greater than 85 percent for the most recent 12-month period ending on the last workday of the most recent calendar quarter prior to submission of an application (turnover rate will be computed in accordance with s. 400.141 (15)(b), Florida Statutes); or have a stability rate indicating that at least 50 percent of its staff have been employed at the facility for at least one year (stability rate will be computed in accordance with s. 400.141 (15)(c), Florida Statutes). _____________________________________________________________________ H. Targeted In-service -- Section 400.23(5)(g), Florida StatutesFacility must have targeted in-service training provided to meet training needs identified by internal or external quality assurance efforts. Describe how in-service training meets the training needs identified by internal or external quality assurance efforts. _____________________________________________________________________ I. State Long Term Care Ombudsman Council Review -- Section 400.23(5)(f), Florida StatutesIn accordance with s. 400.23(5)(g), Florida Statutes and 59A-4.205, Florida Administrative Code, the State Long-Term Care Ombudsman Council will also review this application. J. Best PracticesDescribe the facility's best practices and the resulting positive resident outcomes. _____________________________________________________________________ K. Letters of RecommendationPlease attach relevant letters of recommendation for the Gold Seal Award. L. Presentation to the Governor's Panel on Excellence in Long Term Carea. Would you like an opportunity to make a presentation to the Governor's Panel on Excellence in Long Term Care regarding this facility? Yes No b. Person(s) who will present this recommendation to Gold Seal Panel:
M. Site Visit by Panel Members -- Preferable time frame for site visit: _________________________
Appendix G. Funding of Quality Improvement ProgramsCenters for Medicare and Medicaid ServicesCMS Program Memorandum DEPARTMENT OF HEALTH & HUMAN SERVICES Ref: S&C-03-08 DATE: December 12, 2002 PurposeThe purpose of this policy letter is to reiterate the role and function of surveyors during the survey process on the issue of consultation, technical assistance, and sharing best practice information. PolicyIn accordance with State Operations Manual (SOM), Section 9, Appendix P, page 77, Information Transfer, "the State should provide information to the facility about care and regulatory topics that would be useful to the facility for understanding and applying best practices in the care and treatment of the long term care residents. This information exchange is not a consultation with the facility, but is a means of disseminating information that may be of assistance to the facility in meeting long term care requirements." The intent is to allow surveyors to provide reference information regarding best practices to assist facilities in developing additional sources and networking tools for program enhancement. State Health Facility Surveyors, however, should not act as consultants to nursing homes. The nursing home is responsible for correcting its deficiencies. State Operations Manual, §2727, provides direction regarding Limitations on Technical Assistance Afforded by Surveyors. It is not the surveyors responsible to delve into the facility's policies and procedures to determine the root cause of the deficiency or to sift through various alternatives to suggest an acceptable remedy. When the State Agency conducts a revisit, it is to confirm that the facility is in compliance with the cited deficiencies, not whether it implemented the suggested best practices, and has the ability to remain in compliance. Effective Date: N/A Training: The information contained in this announcement should be shared with all survey and certification staff, their managers and the state/RO training coordinator. /s/ Survey and Certification Regulations: Staffing and Training Expenditures (432.50) Subpart C--Staffing and Training Expenditures1§ 432.45 Applicability of provisions in subpart. The rates of FFP specified in this subpart C do not apply to State personnel who conduct survey activities and certify facilities for participation in Medicaid, as provided for under section 1902(a)(33)(B) of the Act. [50 FR 46663, Nov. 12, 1985; 50 FR 49389, Dec. 2, 1985] § 432.50 FFP: Staffing and training costs. (a) Availability of FFP. FFP is available in expenditures for salary or other compensation, fringe benefits, travel, per diem, and training, at rates determined on the basis of the individual's position, as specified in paragraph (b) of this section. (b) Rates of FFP. (1) For skilled professional medical personnel and directly supporting staff of the Medicaid agency or of other public agencies (as defined in § 432.2), the rate is 75 percent. (2) For personnel engaged directly in the operation of mechanized claims processing and information retrieval systems, the rate is 75 percent. (3) For personnel engaged in the design, development, or installation of mechanized claims processing and information retrieval systems, the rate is 50 percent for training and 90 percent for all other costs specified in paragraph(a) of this section. (4) [Reserved] (5) For personnel administering family planning services and supplies, the rate is 90 percent. (6) For all other staff of the Medicaid agency or other public agencies providing services to the Medicaid agency, and for training and other expenses of volunteers, the rate is 50 percent. (c) Application of rates. (1) FFP is prorated for staff time that is split among functions reimbursed at different rates. (2) Rates of FFP in excess of 50 percent apply only to those portions of the individual's working time that are spent carrying out duties in the specified areas for which the higher rate is authorized. (3) The allocation of personnel and staff costs must be based on either the actual percentages of time spent carrying out duties in the specified areas, or another methodology approved by HCFA. (d) Other limitations for FFP rate for skilled professional medical personnel and directly supporting staff--(1) Medicaid agency personnel and staff. The rate of 75 percent FFP is available for skilled professional medical personnel and directly supporting staff of the Medicaid agency if the following criteria, as applicable, are met: (i) The expenditures are for activities that are directly related to the administration of the Medicaid program, and as such do not include expenditures for medical assistance; (ii) The skilled professional medical personnel have professional education and training in the field of medical care or appropriate medical practice. ''Professional education and training'' means the completion of a 2-year or longer program leading to an academic degree or certificate in a medically related profession. This is demonstrated by possession of a medical license, certificate, or other document issued by a recognized National or State medical licensure or certifying organization or a degree in a medical field issued by a college or university certified by a professional medical organization. Experience in the administration, direction, or implementation of the Medicaid program is not considered the equivalent of professional training in a field of medical care. (iii) The skilled professional medical personnel are in positions that have duties and responsibilities that require those professional medical knowledge and skills. (iv) A State-documented employer-employee relationship exists between the Medicaid agency and the skilled professional medical personnel and directly supporting staff; and (v) The directly supporting staff are secretarial, stenographic, and copying personnel and file and records clerks who provide clerical services that are directly necessary for the completion of the professional medical responsibilities and functions of the skilled professional medical staff. The skilled professional medical staff must directly supervise the supporting staff and the performance of the supporting staff's work. (2) Staff of other public agencies. The rate of 75 percent FFP is available for staff of other public agencies if the requirements specified in paragraph (d)(1) of this section are met and the public agency has a written agreement with the Medicaid agency to verify that these requirements are met. (e) Limitations on FFP rates for staff in mechanized claims processing and information retrieval systems. The special matching rates for persons working on mechanized claims processing and information retrieval systems (paragraphs (b)(2) and (3) of this section) are applicable only if the design, development and installation, or the operation, have been approved by the Administrator in accordance with part 433, subchapter C, of this chapter. [43 FR 45199, Sept. 29, 1978, as amended at 46 FR 48566, Oct. 1, 1981; 50 FR 46663, Nov. 12, 1985] § 432.55 Reporting training and administrative costs. (a) Scope. This section identifies activities and costs to be reported as training or administrative costs on quarterly estimate and expenditure reports to HCFA. (b) Activities and costs to be reported on training expenditures. (1) For fulltime training (with no assigned agency duties): Salaries, fringe benefits, dependency allowances, travel, tuition, books, and educational supplies. (2) For part-time training: Travel, per diem, tuition, books and educational supplies. (3) For State and local Medicaid agency staff development personnel (including supporting staff) assigned fulltime training functions: Salaries, fringe benefits, travel, and per diem. Costs for staff spending less than full time on training for the Medicaid program must be allocated between training and administration in accordance with § 433.34 of this subchapter. (4) For experts engaged to develop or conduct special programs: Salary, fringe benefits, travel, and per diem. (5) For agency training activities directly related to the program: Use of space, postage, teaching supplies, and purchase or development of teaching materials and equipment, for example, books and audiovisual aids. (6) For field instruction in Medicaid: Instructors' salaries and fringe benefits, rental of space, travel, clerical assistance, teaching materials and equipment such as books and audiovisual aids. (c) Activities and costs not to be reported as training expenditures. The following activities are to be reported as administrative costs: (1) Salaries of supervisors (day-to-day supervision of staff is not a training activity); and (2) Cost of employing students on a temporary basis, for instance, during summer vacation. [43 FR 45199, Sept. 29, 1978, as amended at 44 FR 17935, Mar. 23, 1979] CMS Program Memorandum DEPARTMENT OF HEALTH & HUMAN SERVICES Ref: S&C-02-42 DATE: August 8, 2002 The purpose of this memorandum is to provide information regarding how states may use CMP funds collected from nursing homes that have been out of compliance with Federal requirements. It has come to our attention that guidance is needed to ensure that states use CMP funds in accordance with the law and in a consistent manner, while maintaining some flexibility in the use of those funds. Background -- States collect CMP funds from Medicaid nursing facilities and from the Medicaid part of dually-participating skilled nursing facilities (SNFs) that have failed to maintain compliance with Federal conditions of participation. These CMP funds are state, not Federal funds. CMP funds collected from Medicare-participating SNFs and the Medicare part of dually-participating SNFs are Federal funds and are returned to the Medicare Trust Fund. Section 1919(h)(2)(A)(ii) of the Social Security Act (the Act) provides that CMP funds collected by a state as a result of certain actions by nursing facilities or individuals must be applied to the protection of the health or property of residents of nursing facilities that the state or the Secretary finds deficient. These actions include CMPs assessed against:
The Act cites three examples of uses for CMPs:
The regulations, at 42 CFR 488.442(g), contain similar language, with some very minor wording changes that make it clear that the costs of relocation of residents to other facilities are for state costs. The regulations also indicate that the personal funds lost at a facility are the result of actions by the facility or by individuals used by the facility to provide services to residents. Section 7534B of the State Operations Manual (SOM) contains similar language, but specifies that the funds must be used to protect the health or property of residents of deficient facilities. In the preamble to the final enforcement regulations published on November 10, 1994, we indicated that the law suggests that CMP revenues be applied to administrative expenses rather than direct care costs, although it is clear that states have broad latitude to determine which of these types of expenses best meet the needs of their residents (page 56210 of the Federal Register, Volume 59, No. 217). Further, the preamble is very clear that the Act permits each state to implement its own procedures with respect to the use of CMPs. Our previous direction to CMS regional offices has been that the specified uses of CMP funds in the Act and section 488.442(g) are not exhaustive, that states need flexibility in determining the appropriate use of funds, and that regional offices have some oversight responsibility. Beyond this, we have not provided general guidance to all states and regional offices on what is considered appropriate use of these funds within the scope of the law and regulations. Due to the lack of guidance, a number of states have been reluctant to use a majority of the money. As a result, some states have a significant amount of money on deposit and this amount is continuously growing. Flexibility in Use of CMP Funds -- While the Act provides states with much flexibility to be creative in the use of CMP funds, this flexibility is limited by the requirement that CMP funds are to be focused on facilities that have been found to be deficient. However, the law does not specify when a facility must have been determined to be deficient to qualify for benefits under a state project funded by CMPs. Most nursing facilities have had one or more deficiencies either recently or in the past. Rather than setting forth rigid criteria on when it is that a facility must have been deficient to be an eligible target for the application of CMP revenues, we believe that the best course is to offer states maximum flexibility to make this determination. Apart from this, we believe that projects funded by CMP collections should be limited to funding on hand and should be relatively short-term projects. Each state is responsible for ensuring that CMP funds are applied in accordance with the law. Regional oversight should be general in nature, responding to questions from states or commenting on the occasional project proposal submitted for regional office input, but there is no requirement that a regional office review and approve each state project before it is implemented. Appropriate CMP Fund Use --As we stated in the preamble to the 1994 final enforcement regulations, CMP revenues should be spent on administrative expenses, rather than direct care costs, as applied to deficient facilities. If the purpose of the state project is related to deficient practice, the CMP funds could be used to prevent continued noncompliance by nursing facilities through educational or other means. For example, to address particular areas of noncompliance, a state could develop videos, pamphlets, or other publications providing best practices, with these educational materials being distributed to all deficient nursing facilities. Other uses could include, for example, the development of public service announcements on issues directly related to the identified deficient area, and employment of consultants to provide expert training to deficient facilities. North Carolina and other states have issued grants to several nursing facilities to fund Eden Alternative Projects, which provide training and other services necessary to support the use of animals in nursing facilities for therapeutic purposes. Because CMP funds collected by a state are state funds, the state may use the money for any project that directly benefits facility residents, in accordance with section 1919(h)(2)(A)(ii) of the Act, including funding an increase in ombudsman services. Inappropriate CMP Fund Use -- We believe that it is not appropriate for states to use CMP funds for a loan to a deficient facility that is having financial difficulty meeting payroll or paying vendors. As pointed out in the preamble, if the CMP is used by the facility to correct the noncompliance that led to its imposition, it is, in effect, not a remedy. If you believe that a state is not spending collected CMPs in accordance with the law or regulations, or not at all, you should refer this matter to your regional office account representative so that he or she may discuss this matter with the state. Effective Date: This guidance is effective on the date of issuance. Training: This policy should be shared with all survey and certification staff, surveyors, their managers and the state/regional training coordinator. /s/
Which of the following associations was established in 1840 to represent the interests of physicians across the us?Founding of the AMA
An 1845 resolution to the New York Medical Association by Dr. Nathan S. Davis, calling for a national medical convention, led to the establishment of the American Medical Association (AMA) in 1847.
What are quality measures?Quality measures are tools that help us measure or quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems that are associated with the ability to provide high-quality health care and/or that relate to one or more quality goals for health care.
How can continuity and coordination of care increase patient safety quizlet?Continuity and coordination of care increase patient safety because it ensures that the patient is always receiving the proper treatment to highest level of care and when the services rendered are completed, the coordination ensures that even after discharge, the patient is sent home with the proper instructions and ...
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