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


Over the last several years, policy-makers in Texas have undertaken several initiatives designed to address long-standing quality issues. According to those we spoke with, legislative activities and related administrative actions in recent years up through the 2000-2001 biennium tended in the direction of toughening regulations, enforcement, oversight, and accountability. But this direction was reversed (or more balance was introduced, depending on one's perspective) during the 77th legislative session.

Many of the initiatives during the "get tougher" period relate to survey activities and/or provider reimbursement and hence are outside the scope of this project. For example, during the FY 2000-2001 biennium, the legislature mandated a change in the Medicaid payment formula designed to enhance accountability for spending on direct care and encourage improved nursing home staffing. Some of the quality improvement programs described below have their origins during the same period. For example, the state implemented one of the nation's first web-based consumer information systems with facility-specific quality rankings in 1999 and substantially enhanced the system the following year. In addition, the 76th Legislature (2000-2001) mandated and funded the first two annual statewide reviews of quality to identify and quantify specific quality issues.

The Nursing Home Quality of Care Act of 2001 passed during the 77th legislative session and is widely referred to as "Senate Bill 1839." By many accounts, it reflected a more provider-friendly legislative stance. That bill mandated the Quality Monitor program and several other initiatives designed to improve communications (or reduce friction) between providers and the state regulatory agency. They were funded by a shift of approximately $5 million in state and federal funds from the survey and complaint investigations to these alternative activities. This amounted to 82 FTEs transferred out the survey function by the legislature, of which 50 were transferred to the Quality Monitor Program, 16 to a joint training initiative, 14 to function as liaison with providers, and two to a program for resolving conflicts over survey findings. For this reason, the initiatives were seen by some as an effort to gut the regulatory system, which lost approximately 22 percent of its workforce.

While there was general agreement among those we spoke to regarding the origins of key features of SB 1839, the precise origin of the controversial funding mechanism (which was contained in a rider to the appropriations bill) was obscure, with both nursing home associations disclaiming responsibility. Some we spoke to, notably THCA staff, described the intent of SB 1839 as a good faith effort to implement new ways of improving quality, emphasizing greater collaboration between the state and providers, with the state helping by sharing its expertise rather than simply acting as a policeman. Some reported that SB 1839 had its origins in a call from a state senator long active in nursing home quality issues to various stakeholders for ideas about improving quality. The Quality Monitor program was suggested by THCA, based on similar legislation recently passed in Florida.

Responsibility for implementing the quality improvement projects contained in SB 1839 fell to the Department of Human Services (DHS), with the Quality Monitoring program assigned to Dr. Cortes' Medical Quality Assurance group. Since the law was quite general with regard to the Quality Monitor program, DHS leadership tried to fashion a program that was consistent both with the law and on-going efforts such as the statewide quality review and quality reporting system. The resulting program, described below, is significantly different from the Florida program with regard to key details. Two meetings with stakeholders and an outside facilitator were held by DHS to solicit ideas regarding details of the Quality Monitor program. A major concern expressed by consumer representatives at those meetings was the lack of any way for the State to enforce recommendations for quality improvement that might emerge from visits by the new Quality Monitors to facilities. Some saw the new program as a waste of resources because it "lacked teeth". Some providers, however, asserted that whole point of the new program was to try something different from the old regulation and enforcement paradigm, arguing for complete separation of the Quality Monitor program and survey efforts. The compromise fashioned by DHS was to keep the Quality Monitor program and survey separate with two exceptions. First, as specified in the law, Quality Monitors are to report any observed instances of immediate jeopardy. Second, Quality Monitor reports are available over the IntraNet to surveyors and are reviewed as part of preparation for surveys.

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