This section includes a brief description of each of Maine's quality improvement programs followed by a discussion of program funding, governance and the management and staffing structure. The following quality improvement programs were reviewed:
- Behavior Consultation;
- Best Practices; and
- Minimum Staffing Ratios.
Laura Cote RN is the sole technical assistant in Maine, providing on-site consultation to any long-term care facility (nursing facilities, assisted living facilities, intermediate care for the mentally ill, facilities caring for head injured, adult family care homes and boarding homes) on problem resident behaviors any where in the state. Growing out of her experience as a member of a transition team closing a facility that cared for primarily psychiatric residents, she became aware of the need for support and education for long term care staff. She currently provides consultations in the morning and inservice programs in the afternoons on a full-time basis, working from her home office.
Technically an employee of the Division of Licensing and Certification, she receives referrals from facilities and schedules on-site visits and inservice programs throughout the state. Ms. Cote describes the goals of these services as "to assist staff in dealing more effectively with difficult behaviors by giving them a better understanding of the resident, 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."6 Ms. Cote, depending on the severity of the problem, prioritizes responses to facility requests. Visits are generally made within two weeks of the request. Inservice programs are very popular and are currently being booked well into 2003.
On-site consultation visits involve a chart review, problem-solving sessions with staff (including all staff involved in care), a brief meeting with the resident, written recommendations, and a follow up if needed. When speaking with the staff during the problem solving session, they discuss the problem behaviors in detail, including what the warning signs are, what helps, and what doesn't help. Using staff input, she writes her recommendations by hand because she believes that they are more personal. The recommendations are geared to the care providers and reflect the information that they offered in the earlier session. Copies of her recommendations are forwarded to the facility and to the Division of Licensing and Certification. Facility recommendations are available for surveyors' review although facilities are not held accountable for implementing Ms. Cote's recommendations. Appendix B contains a sample of the facility feedback report that is prepared at the end of a behavioral consultation visit.
Ms. Cote has also developed seven in-service programs, which she conducts at facilities on request. Program topics include: Behavioral Approach, Documentation of Behaviors, Alzheimer's--Practical Hints for Caregivers, Intimidating Behaviors, Problem Solving for Difficult Behaviors, Behavior Profile Cards, and Elopement--Risk Factors and Prevention. In-service outlines are included in Appendix B.
No formal evaluation has been done, but Ms. Cote distributes evaluation sheets intermittently to see if there are ways she can improve her service.
Best Practice workshops were mandated as part of the April 2000 legislation to address nursing home issues. The Department of Human Services was charged with participating in a "series of best practices forums to provide educational workshops and opportunities to providers of long term care services." Led by the Assistant Director of Licensing and Certification, a task force was assembled to implement the legislation. Beginning first with determining a definition of a best practice the task force proceeded to identify topics and plan two workshop programs.
The first program on Nutrition and Hydration was an all day workshop offered in two locations. It began with a presentation on the federal regulations regarding nutrition and hydration led by a federal surveyor followed by a panel presentation by providers who discussed nutritional practices that worked best for them. Prior to the workshop, all providers in the state had been asked to submit examples of nutritional best practices. Panel participants were selected from those who had provided a best practice. The audience included administrators, directors of nursing, staff nurses and nursing assistants. The Licensing and Certification division reported that 90 percent of all homes in the state sent staff to one of the workshops. The second program was on Incontinence and featured an expert speaker. The audience consisted mainly of nurses because of the more clinical nature of the forum. The second workshop was not as well attended as the first due to inclement weather on the scheduled date. No formal evaluation of the impact of either program has been conducted as yet.
Minimum Staffing Ratios
Also included in the April 2000 legislative mandate was an increase in nurse staffing requirements. Nurse staffing is defined in terms of ratios of direct care staff to residents by shift. Direct care staff include charge nurses, medication nurses and aides and nursing assistants, but not nurse managers, supervisors, directors of nursing or MDS coordinators. Day shift ratios increased from 1:8 to 1:5; evening shift ratios increased from 1:12 to 1:10; and night shift ratios increased from 1:20 to 1:15. Staffing is reviewed during the annual survey (and during any complaint investigations related to staffing) for a two-week period prior to the date of survey. If problems are noted, surveyors will review other periods as well. If a facility is out of compliance on one shift on one day, they may be cited.
Consumer Satisfaction Survey
Funds to develop a consumer satisfaction survey were included in the April 2000 legislation. Proposals were solicited and a contract was awarded in the Fall of 2002 to Market Decisions, LLC, a Maine survey research firm. This company will conduct a face-to-face survey of a sample of nursing facility residents to determine their satisfaction with their surroundings and the care they receive. The study report is expected in late Spring 2003.
6. Laura Cote. Description of Behavior Management Consultation. September 2002.