As 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.