State Nursing Home Quality Improvement Programs: Site Visit and Synthesis Report. 9.1 Technical Assistance Programs


While 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.

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