All 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.