Missouri was selected for a state site visit because of the project team's interest in the quality improvement projects that have been implemented in the state by Marilyn Rantz and her colleagues at the University of Missouri-Columbia Sinclair School of Nursing. They have developed and implemented the following quality improvement programs in the state: the Missouri "Show-Me Quality Indicator Report" (implemented in 1999), the Quality Improvement Program for Missouri (QIPMO) (pilot tested in 1999 and implemented in 2000), a staff education program for the state's surveyors (which started in the early 1990s), a support group for MDS coordinators (which started in 2001), and a nursing home staff education program (which started in 1997). They think of these as various components of a single quality improvement effort rather than separate programs.
Missouri is the only state with this type of partnership between the state survey agency and a university. The QIPMO program includes on-site technical assistance, educational programs and support groups for facility staff and an educational component for survey agency staff. A Best Practices program is also funded by the state and run by Central Missouri University.
Abt staff members Alan White and Donna Hurd spent three days in Jefferson City and Columbia, Missouri in July 2002, meeting with state survey agency staff, ombudsman, provider association staff and members, state Quality Improvement Organization (QIO) staff, QIPMO nurses and developer Marilyn Rantz as well as facility staff who had participated in QIPMO visits. Researchers were also allowed to accompany QIPMO nurses on a site visit to observe the TA visit in progress. The following individuals agreed to participate in discussions with the researchers:
- Missouri Department of Health and Senior Services/Division of Health Standards and Licensure, Section for Long-Term Care Regulation
- David Morgan, Manager
- Lois Kollmeyer RN, Director
- Darrell Hendrickson, Deputy Division Director
- Betty Markway RN MSN, State MDS Coordinator
- Missouri Department of Health and Senior Services, Senior Services and Regulations, State Office of Long-Term Care
- Carol Scott, State Ombudsman
- Missouri Association of Health Care (AHCA Affiliate)
- Marlene Anderson
- Terri Lueckenotte, Administrator, Capital Healthcare Center
- David Duncan, President, Tiffany Care Centers, Inc.
- Tim Francka, Administrative Director of Long Term Care Facilities, Citizens Memorial Healthcare
- Missouri Association of Homes for the Aging (AHSA Affiliate)
- Denise Clemonds, Executive Director
- Patricia Kapsar, Vice President and Corporate Compliance Officer, Bethesda Health Group, Inc.
- University of Missouri-Columbia, Sinclair School of Nursing
- Marilyn Rantz, Ph.D, RN, NHA, FAAN
- Any Vogelsmeier, MSN, RN, CS, GCNS
- De Minner, RN
- Steven Miller, Program Coordinator
- Not-For-Profit Facility--122 Beds
- Director of Nursing
- Not-For-Profit Facility--120 Beds
- Assistant Director of Nursing
- Charge Nurses
- Physical Therapist
- Director of Nursing
- Missouri Quality Improvement Organization
- Catherine Gill, MS, PT, MHA, Director, Nursing Home and Home Health Services
- Carolyn Spradlin RN, BSN, Quality Specialist, Nursing Home and Home Health Services
- Deborah Finley, Director, Communications and Beneficiary Outreach Services
- Carol Beahan, Communication Specialist
Marilyn Rantz and her colleagues at the University of Missouri-Columbia Sinclair School of Nursing were our primary contacts for the Missouri site visit. Dr. Rantz was very generous with her time providing information on state politics, history, development and implementation of the various components of the program both prior to our visit and while we were there. The two QIPMO nurses with whom we met, Amy Vogelsmeir and De Minner were extremely helpful in explaining and demonstrating their role in the program as well as the program's philosophy and in arranging for us to accompany them on a visit. Everyone that we contacted prior to our arrival was open to participating in discussions. Both provider associations invited members in to their office for meetings. Initially, the executive director of the AHCA affiliate had responded that he did not believe that many of his member facilities had participated in the QIPMO program. When assured that the research team was also interested in the reasons that facilities may have chosen not to participate, he was fully cooperative and invited member facilities to be present for our meeting. Interestingly, he was not able to be at the meeting as he was testifying in a lawsuit brought by the association against the governor over nursing home reimbursement. Our contact at the state survey agency included his immediate supervisors in our meetings as well as the individual who had had the most contact with the QIPMO nurses. The Missouri QIO director of nursing home activities contacted us prior to our site visit and requested that in addition to a scheduled meeting with her and members of her staff that she be allowed to sit in on visits with other groups as she too was gathering information on the QIPMO program in conjunction with their work for CMS on the Nursing Home Quality Initiative.
Prior to the on-site visit, factual information on the quality improvement program was gathered from a literature review, stakeholder discussions and Missouri DHHS and University web sites. 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;
- Evaluation--indicate current and planned formal evaluation program(s).
The table was forwarded to Marilyn Rantz 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 table as a starting point to develop discussion questions that focused on more in-depth issues. Letters of endorsement explaining the project goals, state selection and discussion processes were formulated and sent to prospective participants. In response to a request by the AHCA affiliate, letters of invitation to participate in group discussions were written and forwarded to the provider associations for use with their members. Follow-up phone calls were made to arrange for convenient dates and times for meetings.
Meetings with the survey agency staff, provider association staff and members, ombudsman, university, state QIO and nursing 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 QIPMO nurses at an off-site location and then accompanied them to the nursing facility to observe the technical assistance visit.
Discussions were generally loosely structured with researchers presenting both prepared and spontaneous questions and recording participants' responses in writing.