Maine, Texas, Florida, Maryland and Washington all reported anecdotal comments on the impact of their TA program on resident quality of life and quality of care issues. For long running TA programs like Maine's and Washington's, participants made relatively strong statements on the impact of their programs. Maine's program was praised by every participant as improving the quality of life for the affected residents. Providers believed that the quality of life for the residents referred to the behavioral consultation program was definitely improved, because staff were able to provide better care to a difficult population. Anecdotal feedback from survey staff, the ombudsman, and facilities indicated that the consultations have led to changes in plans of care that have had positive results for both residents and staff. LTC survey staff from the state indicated that, based on informal feedback, the education and support given to staff has decreased medication use among the residents and the number of discharges due to behavioral issues.
In Washington, program staff reported that they believe the TA program is positively affecting outcomes and quality because of informal feedback they receive from providers and stakeholders. Providers and ombudsmen with whom we held discussions noted ways in which they thought the TA program positively affected quality. For example, one provider stated that a good TA nurse can help facilities prioritize quality problems and can help new Directors of Nursing and facility staff to improve quality. An Ombudsman stated that the TA program has a positive effect because it promotes taking care of problems at an early stage. Many respondents viewed good performance on the survey as indicating better quality and indicated that TA visits helped facilities perform better on the survey.
Comments on programs implemented more recently were more tentative, especially in Texas, with many respondents adopting a "wait and see" attitude.
On the positive side, in every state there were participants who said the TA program was helpful, was a good resource for clinical and/or regulatory information, had taught or helped providers improve a skill, and represented a welcome change from the traditional adversarial relationship between provider and LTC survey staff. Providers reported that in many cases they value the consultative advice provided, saying that for some it has changed the relationship between the state and providers for the better. Participants reported learning investigative and analytic skills from TA that they are then able to use to review current facility processes. The shift in focus from deficiencies to quality improvement is also seen as positive. Some survey agencies even reported that providers have fewer complaints about the survey process.
Negative comments are more specific to the individual state program. Lack of consistency between surveyor and TA information was noted as a problem in Washington and Florida. In Florida particularly, providers noted that TA staff hired when the program was initially legislated were former surveyors receiving a promotion, but that those brought in as part of subsequently legislated program changes were not experienced in long-term care, geriatric clinical issues, or the regulations--and thus were less helpful to providers. Florida providers also noted that the value and usefulness of the TA program, which reflects program staff and leadership, appears to vary considerably by region. Both Florida and Washington discussion participants reported problems with the frequency and regularity of TA visits. In each state, visits are mandated to occur on a regular basis, but sometimes do not, leading to distrust of program staff and perceptions of reduced effectiveness. In both these states, TA staff are also utilized for surveyor tasks. Lastly, in Missouri and Texas, providers said they are occasionally overwhelmed by the amount and complexity of information provided by the TA program. Missouri TA staff are advanced practice nurses employed by the university school of nursing, who utilize clinical studies as guidance for providers. In Texas the TA staff promote expert evidenced based practice guidelines developed by academic, clinical, and medical experts. Respondents in Texas reported being often uncertain how to use all the information and for how much of it they will be held accountable.
The Florida and Washington programs, as noted, both involve TA staff functioning in multiple roles. Washington's TA staff act as surveyors on occasion and Florida's TA staff monitor facilities that are closing or in immediate jeopardy. In these states, facilities said they need to be aware of these differing functions and that, depending on the situation, the role of the TA and relationship with the facility may change. These seeming areas of overlap between TA and enforcement are seen by some to have a positive impact on quality, adding "teeth to be able to penalize facilities that don't perform." But others see them as negatively impacting the relationship and any atmosphere of openness between the facility and agency staff. Respondents from states where TA staff performed multiple roles made the point that where there are competing demands on staff who perform both roles, the TA role is often the one that suffers. More work is needed to evaluate which strategies most effectively change the culture of care giving.