This report describes our review of the nursing home quality improvement programs initiated by the State of Florida. It begins with background information on the programs and how the visit and discussions were structured, and continues with a brief account of the origin and rationale for the programs. A description of the programs follows, along with the research team's findings. These findings are based on discussions with state employees, nursing facility respondents, and consumer representatives) regarding the perceived strengths and weaknesses of the programs. A discussion of the impact these programs have had on the quality of life and quality of care of Florida's nursing home residents follows. The report concludes with suggestions from program designers and participants to other states that might want to implement similar programs, a discussion of the sustainability of the various programs, and the respondents' opinions on the role of the Federal Government in quality improvement in nursing facilities.
The study's Technical Advisory Group recommended that Florida be selected as a site visit state largely because of the state's Quality Monitoring program, a technical assistance program that was established in 1999. The state also has numerous other quality improvement programs, including recognition and reward programs and training/education efforts. In addition, the state has a public reporting system, risk management requirements, and mandated increases in minimum direct care staffing. All of these measures stem from two legislative mandates--the first passed in 1999 (HB 1971), and the second, SB1202, which followed in 2001. Each mandate was implemented in direct response to concerns regarding the quality of care in Florida nursing homes and the increase in the number of lawsuits filed against nursing homes
Abt staff members Deborah Deitz and Donna Hurd accompanied by Jennie Harvell, project Task Order Officer (TOO), conducted discussions in Florida over a three-day period in September 2002, meeting with state survey agency staff, Medicaid staff and researchers, consumer advocates and provider association staff. Researchers were also able to accompany a Quality Monitor on a facility visit and speak with facility staff about the Quality Monitor program. The following individuals agreed to participate in discussions with the researchers:
- Florida Agency for Health Care Administration (AHCA)
- Susan Acker, RN, Ph.D. Head of the Office of Standards and Quality
- Barbara Alford, Head of the Long Term Care Quality Monitor Program
- Donnah Heiburg, Head of the Tallahassee Field Office
- Molly McKinstry, Manager Long Term Care Unit, Bureau of Health Facility Compliance
- Sue Redd, Program Manager
- Diane LoCastro RN, Quality Monitor
- Florida Health Care Association
- William Phelen, Executive Director
- Koko Okano, Health Services Research Analyst
- LuMarie Polivka-West, Director of Quality and Policy Assurance
- Debbie Afassano, RN, Assistant Director of Quality Assurance
- Ann DeSilva
- Providers from eight nursing facilities
- Florida Association of Homes for the Aging
- Erwin P. Bodo, Ph.D., FAHA, COO, Senior Vice President of Reimbursement and Statistical Analysis
- Andrea Lewis RN, Director of Regulations and Compliance
- Providers from five nursing facilities
- Florida Medicaid
- Kenneth L. Thurston, CPA, Assistant Deputy Secretary for Medicaid Finance
- Brian Clark, Medicaid Cost Reimbursement
- Nancy Ross, Ph.D., Chief, Medicaid Research Bureau
- Lori Parham, Ph.D., Medicaid Research Bureau
- Consumer Advocates
- Norma H. Atteberry, RN, BS, Geriatric Consultant/Educator
- Victoria K. Fierro, CPA, Financial Consultant
- Anna Spinella, Advocates committed to Improving Our Nursing (ACTION)
- Barbara Hengstebeck, Coalition to Protect America's Elders
- Lyn Bodiford, AARP
- Department of Elder Affairs
- Martie Daemy, Interim State Ombudsman
- Linda MacDonald M.S, Alzheimer Training Program, Senior Management Analyst II
- University of South Florida
- Kathryn Hyer, DrPA, MPP, Director of the Training Academy on Aging at Florida Policy Exchange Center on Aging
- Larry Polivka, Director of the Florida Policy Exchange Center on Aging
- Debbie Hedgecock, Doctoral Student in Aging Studies
- Christopher Johnson, Ph.D.
Because the provider associations were unable to schedule meetings with their members while the research team was in Florida, conference calls were scheduled in late September/early October to discuss Florida quality improvement programs with Florida Health Care Association and Florida Association of Homes for the Aging members. Conference calls were also used for discussions with the Ombudsman and with staff from the Florida Policy Exchange Center on Aging at the University of South Florida.
Prior to the on-site visit, information on the quality improvement program was gathered from a literature review, stakeholder discussions and the MyFlorida.com website. Information on the following aspects of the programs was gathered and organized in a table:
- Program title;
- Program description;
- Agency contact--the person(s) most knowledgeable about the program protocols and implementation to date;
- Impetus--what prompted the development of the program;
- Designer--identify the individual(s) or group(s) responsible for program design and indicate agency affiliation(s);
- Goals--state the program objectives;
- Funding Source and Amount--state current funding amounts/sources and projections for future periods;
- Program Staff--indicate how many individuals are involved in the program implementation including administrative support, what is the organizational structure;
- Facility Involvement--is this a requirement for all facilities or a voluntary program, how are facilities selected for inclusion, if voluntary?
- Dates--what are the program beginning and end dates; and
- Evaluation--indicate current and planned formal evaluation program(s).
The table was forwarded to the survey agency contact, Dr. Susan Acker, prior to the on-site visit for her to review and provide additional or corrected information. The research team used the factual information in the tables as a starting point to develop interview questions that focused on more in-depth issues. Letters of endorsement explaining the project goals, state selection and interview processes were sent to prospective interviewees. Follow-up phone calls were made to arrange for convenient dates and times for interviews.
Meetings with the survey agency staff, provider associations staff members, Medicaid staff and researchers, consumer advocates and facility staff took place at their respective offices or on-site at the nursing facility and generally lasted one to two hours. The research team met with the Quality Monitoring nurse at the facility and was able to interview her prior to observing the Quality Monitor visit.
Follow-up phone calls were made to participants who were not available to meet with the researchers while on site. These were scheduled in late September/early October and conducted as conference calls with the Abt staff and the ASPE Task Order Officer.