State Nursing Home Quality Improvement Programs: Site Visit and Synthesis Report. Impetus for Missouri's Quality Improvement Programs


The QIPMO programs originated from the vision of Marilyn Rantz and supporters at the Division of Aging. Dr. Rantz holds a Ph.D. in Nursing from the University of Wisconsin-Milwaukee, Masters of Science in Nursing from Marquette University, and Master of Arts in Teaching from the University of Wisconsin-Whitewater. She has also been a nursing home administrator. While at Wisconsin, she worked under David Zimmerman and provided clinical input to the development of the CHSRA quality indicators.

Dr. Rantz was interested in using MDS data to track nursing home quality and came to the University of Missouri because she would have access to MDS data. Dr. Rantz worked with Paul Shumate, who was then the Director of Long-Term Care Regulation to introduce quality improvement programs. He was interested in seeing that the MDS data be used and improved. She began in 1993 to put the research team together.

A statute establishing the Nursing Facility Quality of Care Fund was introduced in 1994 and made effective in 1995. According to a staff member at the Missouri QIO who had been employed in the survey agency for over 20 years, at the time the Quality of Care Fund was introduced, there had been a great deal of tension between facilities and the Division of Aging. The proposal was introduced as a way to use the nursing home fines to fund quality improvement programs--a way to utilize the fines to prevent future fines. The survey agency accepted the proposition because it provided some assistance for facilities in a manner that did not compromise their role in regulatory enforcement. The statue required that any activities funded under this statute had to be approved by both provider associations.

In 1999, the University ran the pilot study testing the impact of using advanced practice nurses to provide technical assistance to nursing facilities. When the pilot demonstrated that on-going on-site visits were effective in improving resident outcomes, Paul Shumate wanted to expand the program to include all nursing facilities. Around the same time, the state auditor reported that the state was behind on their surveys. Missouri requires an annual certification and licensure survey as well as a briefer interim survey. The AHCA affiliate director did not believe that facilities would accept QIPMO visits without some sort of incentive. He promoted the idea of using the QIPMO visit as the interim survey. As Dr. Rantz explained, she was not in favor of this, as she believed the focus of QIPMO visits should be on quality and did not like being this closely linked to the survey process. Resident advocates feared that the change would weaken enforcement mechanisms. Ombudsman and resident advocates agreed with Dr. Rantz on this. However, in an effort to get the program implemented, she went along with the proposal hoping that the process could later be revised. Linkage to the interim survey lasted only about six months--a regulation was passed requiring that all surveys be unannounced and because QIPMO visits were scheduled in advance with facilities, QIPMO visits could no longer take the place of interim surveys.

Recent changes in the organization of the Division of Aging also appear to have had at least some indirect effect on quality improvement programs. During Governor Carnahan's tenure, there had been an attempt to pass a constitutional amendment to create a separate Department of Aging. This was defeated however, in a statewide referendum. After Carnahan's death in October 2000, the acting governor moved the Division of Aging to the Department of Health and Senior Services by means of an executive order. The intent was to focus more attention on aging issues by moving it into a smaller department (the Department of Social Services had at the time over 10,000 employees). According to informants, the move took approximately one year to organize and had just recently been completed. As part of the transition, the Institutional Services Section of the former Division of Aging became the Section for Long Term Care Regulation under the Division of Health Standards and Licensure within the Department of Health and Senior Services.

During our discussions with stakeholders, and in subsequent correspondence with state survey agency personnel, we received differing opinions of the effect of the reorganization. According to some we spoke to, during the reorganization, there has been significant turnover and staff changes at both the surveyor and management levels, with a resultant loss of much "history" and institutional knowledge, particularly related to QIPMO. David Morgan, Manager of the state's Section for Long-Term Care Regulation, stated that there has not been a great deal of turnover in response to the reorganization. He also notes that the changes that have occurred have given the agency "new perspectives that may find other issues with programs prior staff were blind to."

Concern was also voiced that changes that have occurred as a result of the reorganization have strained the ability of the Section for Long Term Care Regulation to operate effectively, and that the agency is not able to target poorly performing facilities as aggressively as it had previously. However, recent audits have identified several areas of improvement in the management and performance of the state's survey agency. The number of facilities receiving notices of non-compliance has remained stable, and it is not clear whether the reorganization has impacted the effectiveness of the state's survey and certification activities.

Regardless of whether the organizational changes have been beneficial or deleterious overall, many stakeholders expressed the concern that the changes, coupled with the state's budget crisis and the new nursing home quality initiatives launched by the state's QIO, have created a tenuous situation for continued QIPMO funding. Dr. Rantz was able to use her analyses of the effectiveness of QIPMO to secure funding for this year, convincing the state that the program is effective in improving nursing home quality and a prudent funding choice in an atmosphere of competing agency needs.

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