Developing outcome measures is a major focus in the health care system and interest in similar measures has appeared in long-term care services. Seventeen states indicated that they are either developing outcome measures for assisted living or were interested in doing so: Alabama, Florida, Idaho, Iowa, Kansas, Maine, Massachusetts, Minnesota, New Jersey, New York, North Carolina, Oregon, Texas, Utah, Vermont, Washington, and West Virginia.
The initiative has gained attention in part as a result of the work of Keren Brown Wilson, President of Assisted Living Concepts, who developed a paper on this area for the American Association of Retired Persons. Based on her work, officials in the Washington Aging and Adult Services Division developed a review guide that operationalizes the principles of assisted living and the concepts of outcome measures and which tested an outcome-based approach to monitoring quality in assisted living facilities. Using this approach, the inspector--prior to monitoring visits--reviews existing information and prepares a plan for the visit. This includes reviewing the files for complaint history, reviewing DOH inspections reports, checking for information from the long-term care ombudsman program, and contacting the case manager to determine whether any concerns have been raised by clients and whether any clients have special needs. The reviews include visits with a sample of Medicaid residents.
During the visit, the monitor meets with the residence administrator who informs the residents of the visit. The monitor compares the list of the residents to the list maintained by the department. Staff provide an escorted walk-through of the residence to evaluate the home-like quality of the facility and observes activities, interactions between staff and residents, laundry areas, availability of a public telephone, posting of resident's rights as well as the numbers for filing complaints. Based on the size of the facility, a sample of residents is selected for interviews, including at least one resident who receives "limited nursing services" and a resident who does not have a person that can intervene on his/her behalf. The monitor reviews a sample of the negotiated service agreements and notes who was involved in developing the agreement, the extent of the resident's needs, and the agreed upon service plan and ensures that the services required to meet the needs have been delivered. A staff member introduces the monitor to the residents included in the sample. The interviews are held to determine what services were provided, if they were adequate to meet the resident's need, and if they were delivered according to the preferences of the resident.
Direct interviews with residents are the central source of information concerning quality of care. Residents are asked about a range of issues that include the appropriateness of and satisfaction with the service received. Residents are asked to identify what services are being received, whether they are received when and in the manner that is needed, who decided when the services would be delivered, whether any needed services are not being received, and any limitations that need to be addressed.
Residents are asked if they feel as though they are treated with dignity and respect, to describe their daily routine, to discuss who makes decisions about routine activities (getting up and going to bed, eating meals, taking baths) and how well the residence respects the resident's preferences.
Privacy issues are addressed by asking whether the mail is opened, how a person makes personal phone calls, whether service needs have been discussed in front of others. Questions are also asked about support for personal relationships and the maintenance of a home-like environment. (Do you like the way your room is arranged and decorated? Are your personal possessions safe? Is the housekeeping satisfactory?) Other areas covered include understanding and perception of the rules, adequacy of health care services, and the resident's sense of well-being. Monitors also make observations about the resident's living area and appearance and, if concerns are observed, first checks the person's preferences and choices before a conclusion is reached.
When negative outcomes are observed, the monitor conducts a more focused and detailed review of the residence in the problem areas to determine whether the facility's administration, policy, procedures or practices are contributing to the outcome. Additional activities include expanding the sample of residents interviewed, more detailed record reviews, and a review of the minutes of the resident council meetings. Monitors will also review the records of residents who have left the residence as well as activity schedules and menus.
Monitors talk with staff and the administrator to discuss observations from the review and to obtain the provider's perspective on service delivery. Monitors may contact family members or case managers before completing a report. The report covers the physical environment; resident's rights concerning privacy, dignity, and choice as well as the awareness of rights; and service delivery.
Other models: Under Connecticut's rules, assisted living services agencies (ALSAs) are required to establish a quality assurance committee that consists of a physician, a registered nurse, and social worker. The committee meets every four months and reviews the ALSA's policies on program evaluations, assessment and referral criteria, service records, evaluation of client satisfaction, standards of care, and professional issues relating to the delivery of services. Program evaluations are also to be conducted by the quality assurance committee. The evaluation examines the extent to which the managed residential community's policies and resources are adequate to meet the needs of residents. The committee is also responsible for reviewing a sample of resident records to determine whether agency policies are followed, services are provided only to residents whose level of care needs can be meet by the ALSA, care is coordinated and appropriate referrals are made when needed. The committee submits an annual report to the ALSA summarizing findings and recommendations. The report and actions taken to implement recommendations are made available to the state Department of Health.
Oregon's rules require providing for ongoing monitoring by the state Senior and Disabled Services Division staff or its designee, usually an area agency on aging. The staff review the service plans of residents for compliance. Written outcome measures covering functional abilities, psycho-social well-being, stability of medical conditions, and client/family satisfaction are examined.
Nearly final rules in Vermont will require facilities to develop quality improvement programs that identify indicators to be used to monitor performance and describe how monitoring will occur. An internal quality committee will be formed that includes the director, a licensed nurse, one other staff member, and others as needed or desired. Committees will meet quarterly and residents are to be able to provide input on satisfaction and review of any quality improvement plans.
Facilities must allow survey staff access to resident assessments and service plans and outcome measures that reflect planned and actual events related to functional abilities, psycho-social well being, stability of medical conditions, and resident satisfaction. Assisted living residences must establish and maintain a written quality assurance plan and a listing of all residents who moved from the facility since the last monitoring visit.