This report describes our review of nursing home quality improvement programs that have been implemented in the State of Texas. We first present background information about the project team's site visit and the history and rationale for Texas's movement toward state-initiated quality improvement. This is followed by a description of each program reviewed by the project team. Findings regarding the strengths and weaknesses (as identified by those who participated in discussions) are presented, as is a discussion of the impact of the QIPs on quality of care and quality of life of nursing facility residents. Finally, lessons learned by the state are presented, along with a brief description of the perceived sustainability of the various QIPs.
Following the completion of the literature review, discussions with stakeholders and the meeting of the Technical Advisory Group, Texas was selected as a site visit state because we were interested in the state's Quality Monitor Program, which started in 2002. Quality Monitoring is a key component of the DHS Long Term Care Quality Outreach program created by Texas Senate Bill 1839 that was passed in 2001. Other components of the program include joint provider/surveyor training and liaison with providers, both of which are designed to improve knowledge of the survey and enhance communication between providers and state regulatory staff.
In addition, Texas has three quality improvement programs that pre-date or were developed independently of the 2001 legislation but that are managed by the same staff as the Quality Monitor Program and are conceptually linked to it. These are:
- The state's Long-Term Care Quality Reporting System, a web-based source of consumer information on nursing home quality;
- The state's Quality Matters (QM) web, a training resource of evidence-based practices meant to help nursing facilities improve their quality of care;
- The Statewide Quality Review Program, a legislatively mandated annual survey of quality issues in Texas nursing facilities.
Abt staff member Christine Hale and consultant Barbara Manard were responsible for the site visit. Over a four-day visit in August 2002, the research team met with individuals involved in the development and operation of relevant programs; held roundtable discussions with 5 providers (who had recently experienced a Quality Monitor visit) at each of the two major provider associations; spoke with representatives and staff from two consumer-oriented organization; and attended a half-day training program for Quality Monitors during which the research staff talked informally with approximately 10 quality monitors. Formal discussions were held with the following people.
- The Texas Department of Human Services
- Bettye Mitchell, Deputy Commissioner for Long Term Care
- Evelyn Delgado, Assistant Deputy Commissioner for Long-Term Care Regulatory
- Leslie Cortes, MD, Director of Medical Quality Assurance
- Jim Lehrmen LMSW-AP, former Deputy Commission for Long-Term Care Regulatory,
- Deirdre Monroe, RPh, PhD, Pharmacy and Nutrition Manager (the Quality Monitor program)
- Benjy Green, Administrative Management (budget and finance)
- Hilda Mikan, RN, BSN, Nurse Manager for the Quality Monitor Program
- Texas Health Care Association (THCA)
- Tim Graves, President
- Robin Hayes, Director of Best Practices
- Roundtable discussion participants:
- An administrator from a 118 bed facility, 20 bed dementia, 40 bed traditional LTC, 60 shot-stay rehabilitation, 15-20 patient outpatient rehabilitation with a 95 percent occupancy rating.
- An administrator from a 117-licensed bed dually certified general nursing facility.
- An Assistant Director of Nursing from a 147 bed facility
- Texas Association of Homes and Services for the Aging (TAHSA)
- Roundtable discussion participants:
- Rose Ireland, RN (TAHSA staff person with particular expertise in quality issues)
- An Executive Director from a not-for-profit 65 Continuing Care Retirement Community Nursing Facility with an 18-bed dementia unit with a 99 percent occupancy rate.
- An Executive Director and Director of Nursing from a skilled nursing facility with 120 beds with no special levels with a 97 percent occupancy rate.
- Texas Advocates for Nursing Home Residents
- Beth Ferris, Legislative Representative
- Texas Department on Aging
- John Willis, LMSW-ACP, State Nursing Home Ombudsman
- Cheryl Cordell, Ombudsman Specialist
- Ola Kidd, Assistant State Long-Term Care Ombudsman
Leslie Cortes, the Director of Medical Quality Assurance, was the primary contact for the Texas site visit. Dr. Cortes oversees most of the quality improvement initiatives discussed below. He is a geriatrician with substantial experience in computer systems and health care quality issues and was responsible for the detailed design and implementation of the Quality Monitor program and several other initiatives discussed below. There were personnel changes in two key positions just prior to our visit. Bettye Mitchell became the new Deputy Commissioner for Long Term Care at the Department of Human Services (DHS) effective July 15, 2002. Evelyn Delgato had just replaced Jim Lehrman who was the Assistant Deputy Commissioner for Long Term Care Regulatory (the agency responsible for the survey and for two initiatives discussed below) for the past five years.
Prior to the on-site visit, factual information on the quality improvement programs was gathered from the literature review; stakeholder discussions held in Washington, DC; the Texas state web site; and preliminary telephone interviews with Dr. Cortes and others. Information on the following aspects of the programs was gathered and organized in a table. Questions were generated for areas where information was lacking or was unclear. Activities that were related or similar to each other were grouped together: Information was organized into the following points:
- Program title with a regulatory reference if applicable
- Program description
- Agency contact
- Development of the program
- Intent/Vision of the program
- Effectiveness of the program
- Relationships among agency staff and other related organizations
- General question
- Lesson Learned
Discussions took place primarily in the offices of agency staff or stakeholders and lasted from one to three hours. Discussions were generally structured with one researcher presenting both prepared and spontaneous questions while the other researcher took notes.