In all our study states except Maine and Missouri, TA initiatives were mandatory for all Medicare and Medicaid certified long-term care facilities in the state. This decision is legislatively imposed in some states, such as Florida. In other states, such as Washington, the mandate is part of state utilization review requirements, which necessarily apply to all Medicaid facilities but not Medicare only facilities. In Maryland, there is no legislation specifically mandating a quality related survey, but state regulations require two annual surveys to be performed for each facility, and the state has chosen to focus its "Second Survey" on quality improvement activities that include technical assistance and sharing of best practices.
The frequency of TA visits in states with mandatory programs varies. In Maryland, TA visits are performed yearly at each facility. In Texas, all facilities have at least one TA visit per year with additional visits prioritized to target those considered likely to be at risk for a poor survey, based on factors such as quality indicator data and previous survey results. Facilities can also request a site visit if they need guidance about an area of care. Florida also ties the frequency of visits to quality concerns. Florida's original legislation was similar to Texas, calling for annual TA visits to all facilities, with more frequent visits to troubled facilities. Current legislation mandates quarterly visits to all facilities and continues the policy of providing additional visits to poorly performing facilities. In Washington state, Quality Assurance Nurses are required by regulation to visit each Medicaid nursing facility at least quarterly.
The two states with voluntary TA programs in the study are Maine and Missouri. These programs focused on quality improvement through consultation focused on helping facilities to improve their care practices rather than through regulatory compliance.
In Missouri, TA visits are provided by nurses employed by the University of Missouri and are voluntary, confidential, and consultative. The consultative focus allows TA nurses to emphasize standards of care and to work with facility staff on improvement efforts that are specific to their facility and resident needs. In 2001, there were 459 site visits in 212 different facilities. This included 164 nursing homes, 20 intermediate care facilities, and 85 residential care facilities (note that some facilities fell into multiple categories). Since the program began in mid-2000, about 270 of the 600 (45 percent) nursing facilities in Missouri have participated in the TA program.12
Missouri's QIPMO program encourages facility participation through the efforts of the staff to publicize the program. The TA staff in Missouri believes that their involvement in support group activities helps increase provider awareness of and interest in the TA program. TA staff coordinates and facilitates monthly MDS Coordinator support group meetings. These meetings aim to (1) improve MDS coding accuracy, (2) enhance job satisfaction for MDS Coordinators and (3) increase overall staff retention rates. In addition, the program receives referrals from surveyors.
Maine's TA program provides behavioral consultation statewide to any long-term facility upon request. Its focus is on improving resident outcomes through a combination of consultative and educational support. There are 126 nursing facilities in Maine, with 7,309 residents reported as of Spring 2001. Maine's TA nurse reports visiting 181 residents from July 2000 through June 2001, and 169 residents from July 2001 through June 2002. No records have been kept to indicate the number of facilities that have been visited.
In Maine, nursing home providers appreciate that the TA is free, that it is not connected to the LTC survey, and involves all facility staff in the process. Some referrals come through the Ombudsman caseworker, who contacts the TA nurse directly or suggests that the facility contact her. But the majority of referrals come from facilities themselves. The TA nurse describes the goals of her services as "to assist staff in dealing more effectively with difficult behaviors by giving them a better understanding of the resident and why the behaviors are occurring, making recommendations, involving them in team problem solving where their input is valued, and providing them the education that will enable them to do their jobs more effectively and safely--as well as improving quality of care and ultimately quality of life for the resident."13 She prioritizes responses to facility requests based on the severity of the problem. Visits are generally made within two weeks of the request.