Participants 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.